1.0 Enrollment
1.1 The contractor
shall develop an enrollment plan to support contractor enrollment
of beneficiaries and report on the implementation of the plan according
to contract requirements. The contractor shall consult with the
Director, TRICARE Regional Offices (TROs) and all Military Treatment Facility
(MTF) Commanders/Enhanced Multi-Service Market (eMSM) Managers where
Prime is offered in developing the enrollment plan.
1.2 The contractor
shall have an enrollment system that supports all enrollment related
activities, i.e., Defense Enrollment Eligibility Reporting System
(DEERS) enrollment applications, and MTF/eMSM enrollment guidelines.
1.3 The enrollment
system shall meet all the TRICARE Systems Manual (TSM) requirements, including
at a minimum, the following:
• Meet all system access requirements.
• Ensure installation
of all hardware.
• Ensure loading
of all software.
• Ensure completion
of all required forms.
• Interface with
Government systems.
1.4 The enrollment
system shall be fully operational 60 days prior to the start of
health care delivery (SHCD).
2.0 Enrollment
Processing
At SHCD, all enrollment actions
will be accomplished by the incoming contractor. If the outgoing
contractor requires a retroactive change, they shall submit their
request to the incoming contractor who will perform the change and
notify the outgoing contractor, when it is complete.
2.1 Enrollment
Processing After The SHCD
Once health
care delivery begins, all enrollment actions will be accomplished
by the incoming contractor.
2.2 Phase-In of TRICARE Prime Enrollment
The contractor shall begin the enrollment
process for the TRICARE Prime Program no later than 60 calendar
days prior to the scheduled SHCD, with new enrollment processing
to begin 40 days prior to the SHCD, subject to the Defense Health
Agency (DHA) approval of systems under the contract.
2.2.1 Enrollment
Actions During Enrollment Dual Processing
2.2.1.1 When the Defense
Manpower Data Center (DMDC) creates the Enrollment Gold File for
the incoming contractor, enrollment dual processing begins (between
45-60 days prior to SHCD). This process creates a future enrollment
to the incoming contractor. The following must be followed until SHCD.
2.2.1.2 For enrollments
in the region with an effective date prior to the SHCD (e.g., active
duty 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. DMDC may run a report
at the end of the transition period that reflects new additions.)
2.2.1.2.1 The outgoing
contractor has until SHCD to send updated fee information to DEERS. Beginning
at the SHCD, the outgoing contractor will work with the incoming
contractor to resolve any discrepancies of cumulative enrollment
fees and paid-through dates on policies.
2.2.1.2.2 Beginning
at the SHCD, the incoming contractor shall send the corrected fee information
to DEERS using Fee/Catastrophic Cap and Deductible (CCD) Web Research
application or the batch fee interface outline in the TSM,
Chapter 3.
2.2.1.3 When a current
enrollment in the region requires deletion with an effective date
prior to the SHCD (e.g., transfers out; disenrollments for failure
to pay fees; cancellations, etc.), when requested by another enrolling
contractor, the incoming contractor must cancel the future enrollment
segment and notify the outgoing contractor when this action has
been completed.
2.2.1.4 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.), when
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 verify/reinstate the future enrollment segment.
2.2.2 In addition
to other contractually required enrollment reports, the contractor,
shall provide progress updates on enrollment activities in accordance
with the Integrated Master Plan /Integrated Master Schedule (IMP/IMS).
2.3 Transfer
Of Enrollment Files
2.3.1 The incoming contractor shall obtain
enrollment policy information from DEERS through an initial enrollment
load file. DMDC will provide the incoming contractor with an enrollment
load file for each contract transition. The outgoing contractor
shall provide
: (1) the additional enrollment information
required for those Active Duty Family Members (ADFMs) enrolled in
TRICARE Prime
residing outside of a
Prime Service Area (PSA) who were granted grandfathered status and
who maintain
ed their
eligibility for TRICARE Prime
and (2) a list of those
beneficiaries living greater than 100 miles from a Primary Care
Manager (PCM) and granted re-enrollment per National Defense Authorization
Act (NDAA) FY 2016, Section 701. The additional enrollment
information shall include, but is not limited to, the original address
of the beneficiary when they were initially grandfathered
or allowed
to re-enroll.
(See Chapter 27 for
more information on these beneficiaries.) The incoming contractor
shall process each enrollment load file within 24 hours or less
from receipt of the file.
2.3.2 No later than the date specified
at the Transition Specifications Meeting, the outgoing South Region
contractor shall provide to the incoming East Region contractor,
the additional enrollment information required for Continued Health
Care Benefits Program (CHCBP) enrollees.
Note: Each
contract transition shall require a global freeze of enrollment.
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.
2.3.3 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.
2.3.4 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 the TSM,
Chapter 3.
2.4 Enrollment Fees
2.4.1 The incoming contractor shall obtain
the cumulative total of enrollment fees and paid- through dates
for the policies from DEERS. The contractor who collects the enrollment
fee shall forward the fees to the Government in accordance with
Chapter 6, Section 1. The outgoing contractor
shall work with the incoming contractor to resolve any discrepancies
of cumulative enrollment fees and paid-through dates within 90 days
of start of the SHCD on policies inherited during the transition.
The incoming contractor shall send the corrected fee information
to DEERS using the Fee CCD Web Research application or the batch
fee interface outlined in the TSM,
Chapter 3.
2.4.2 The incoming
contractor shall obtain information from the outgoing contractor
on fees that are being paid monthly (i.e., by allotment,
recurring credit card, or Electronic Funds Transfer
(EFT) and transition these monthly payment types in
the least disruptive manner for the beneficiary.
2.4.3 The incoming
contractor shall coordinate the transition of allotment data, through
the Performance, Analysis, Transitions, and Integration Section
(PAT&IS) and/or the applicable DHA Program office, with the
Defense Finance and Accounting Service (DFAS), Public Health System
(PHS), and U.S. Coast Guard (USCG) during the transition-in period
of the contract (see the TSM,
Chapter 1, Section 1.1).
2.5 Phase-Out
Of Enrollment Activities
2.5.1 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.
2.5.2 The outgoing
contractor shall complete all pending enrollment actions prior to
the DEERS global enrollment freeze to transition enrollment. Any
enrollment action not completed by the outgoing contractor prior
to the freeze (and after the Gold File is created) will have to
be accomplished following the above procedures.
2.5.3 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. The incoming contractor shall
answer all correspondence in accordance with applicable standards
(see
Chapter 1, Section 3), update DEERS, as appropriate,
and forward the fees to the Government in accordance with
Chapter 6, Section 1.
2.5.4 No later than the date specified
at the Transition Specifications Meeting, the outgoing contractor
shall provide to the incoming contractor, the additional enrollment
information required for those ADFMs enrolled in TRICARE Prime who
reside outside of a PSA who were granted grandfathered status and
maintain their eligibility for TRICARE Prime. The additional enrollment
information shall include, but is not limited to, the original address
of the beneficiary when they were initially grandfathered.
2.5.5 No later than the date specified
at the Transition Specifications Meeting, the outgoing South Region
contractor shall provide to the incoming East Region contractor,
all billing and enrollment information required to administer the
Continued Health Care Benefit Program (CHCBP) for its enrollees.
2.5.6 The outgoing contractor shall terminate
marketing and enrollment activity 40 calendar days prior to the
start of the incoming contractor’s SHCD. 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.
2.5.7 Throughout the transition 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.
3.0 Performance
Readiness Validation (PRV)/Performance Readiness Assessment and
Verification (PRAV)
During transition, the incoming contractor’s
performance readiness status regarding enrollment activities will
be subject to PRV/PRAV reviews as described below.
3.1 Enrollment
PRV
3.1.1 Sixty days prior to SHCD, the contractor
shall validate their enrollment system is fully operational and
meets all contract requirements. The contractor shall demonstrate
the ability to perform all required billing, enrollment, and collection
transactions. Validation shall include demonstrating all hardware/software
is operational, meets system access requirements, and correctly interfaces
with Government systems including the required MTF/eMSM systems.
The contractor shall validate that all enrollment rules are loaded
and that accessible and sufficient staff is hired/trained to perform
at historical levels of enrollment transactions.
3.1.2 Sixty
days prior to SHCD, the contractor shall validate it has begun the
enrollment process for the TRICARE Prime Program and demonstrate
it can perform enrollment transactions with at a 97% accuracy rate
(to be considered accurate, all data elements within an enrollment
must be correct).
3.1.3 Forty-five days prior to SHCD, the
contractor shall validate their billing system is fully operational
and that it has started sending billing notices and processing renewals.
The contractor will validate they have obtained information from
the outgoing contractor on fees that are being paid monthly (i.e.,
by allotment or EFT) and they are transitioning these monthly payment
types in the least disruptive manner for the beneficiary.
3.2 Enrollment
PRAV
3.2.1 The contractor shall comply with
the Government’s approach for assessment and verification of the
contractor’s performance readiness regarding enrollment activities
as described above. If, after review, the Government finds the contractor’s
performance readiness for enrollment processing to be deficient,
the contractor must submit a detailed mitigation plan no later than
10 days business days following the Government’s findings.
3.2.2 Specific
PRAV activities, assessment techniques, and performance readiness
thresholds will be identified by the Government during the Transition
Specification Meeting.