2.0 Performance
Readiness Validation (PRV)/performance Readiness Assessment And
Verification (PRAV)
During transition, the incoming contractor’s
performance readiness status regarding referral management will
be subject to PRV/PRAV reviews as described below.
2.1 Referral
Management PRV
2.1.1 The contractor shall validate establishing
referral management system interfaces with MTF/eMSM referral management
systems. Establishing an MTF/eMSM interface must meet two criteria:
1) MTF/eMSM can send and receive referrals with no technical problems,
and (2) contractor sends ROFRs in accordance with the MTF/eMSM capability
table with 95% accuracy. Milestones for validating MTF/eMSM interfaces
are:
• Fifty percent (50%) of MTF/eMSM interfaces
are established 90 days prior to SHCD.
• Seventy-five percent (75%) of MTF/eMSM
interfaces are established 75 days prior to SHCD.
• Ninety-five percent (95%) of MTF/eMSM interfaces
are established 60 days prior to SHCD.
2.1.2 Sixty
days prior to SHCD, the contractor shall validate its systems can
effectively interface with the Government’s RMS, Defense Enrollment
Eligibility Reporting System (DEERS), TRICARE Regional Offices (TROs),
MTFs/eMSMs, claims, Network Provider Directory, and Network Providers
and the contractor’s portal/web site. The contractor shall inspect,
test, and produce connectivity test results on all interfaces.
2.1.3 Fifty
days prior to SHCD, the contractor shall validate all aspects of
its referral, authorization, ROFR and command approval process by
utilizing test scenarios which include referrals to MTF/eMSM and
Network providers. The validation must encompass all necessary beneficiary
categories to include processing referrals for beneficiaries with
Medicare Part A (but under age 65) and still enrolled in TRICARE
Prime and referrals from United States Coast Guard (USCG) facilities.
The validation must incorporate a review of the contractor’s ability
to utilize open authorizations that were transferred from the outgoing
contractor.
2.1.3.1 The contractor shall validate that
their system can timely and accurately communicate referral, authorization
and ROFR determinations with beneficiaries, network providers, MTFs/eMSMs, Government
systems and claims systems without technical problems. The contractor
shall demonstrate beneficiary and provider ability to view/print
authorization from the contractor’s web site/portal. The contractor
shall demonstrate accurate letter generation.
2.1.3.2 The contractor’s
validation shall demonstrate their referral management system’s
ability to accurately process 90% of referrals within two working
days and 100% within three working days. The contractor shall validate
its Referral Management beneficiary communications system--approval/denial letters,
etc. is accessible by MTFs/eMSM, TROs, and beneficiaries.
2.1.3.3 The contractor
shall validate that referrals and ROFRs processed meet Program requirements
with a 95% accuracy rate. To be considered accurate, processed referrals/ROFRs
shall include:
• Correct Beneficiary.
• Correct Beneficiary Demographics.
• To include sponsor’s last four Social Security
Number (SSN) or Department of Defense (DoD) ID Number.
• Date of Birth (DOB).
• Unique Identifier Number (UIN) is present
if MTF/eMSM generated request.
• Correct Servicing Provider.
• Correct Servicing Specialty.
• Correct Episode of Care (EOC).
• Evaluate and Treat.
• Evaluate only.
• Number of visits.
• Length of authorization.
• Range of Current Procedural Terminology
(CPT) codes.
2.2 Referral
Management PRAV
2.2.1 The contractor shall comply with
the Government’s approach for assessment and verification of the
contractor’s performance readiness regarding referral management
as described above. If, after review, the Government finds the contractor’s
performance readiness for referral management to be deficient, the
contractor must submit a detailed mitigation plan no later than
10 business days following the Government’s findings.
2.2.2 Specific
PRAV activities, assessment techniques, and performance readiness
thresholds will be identified by the Government during the Transition
Specification Meeting.