1.0 Timeliness And Quality Standards
Of Performance
The
contractor shall provide or arrange for
delivery of quality, timely health care services and shall provide 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 established
standards of performance which DHA other
Government agencies will monitor 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 business days following
receipt of the request and all required information.
• One hundred
percent (100%) of such requests within five business 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 business
days.
• One hundred percent (100%)
of all requests within three business days.
1.2.2 A minimum of 96% of referrals
for
TRICARE Prime enrollees who reside
in TRICARE Prime Service Areas (PSAs) and
TRICARE Prime
enrollees who reside outside PSAs and have waived the travel-time
access standards shall be to the
Market/Military
Treatment Facility (MTF)
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 payer; and
• Market/MTF 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 the Continental United States (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 Market/MTF 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 TRICARE Prime Remote (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. This
excludes non-network claims due to response to national public health
emergency or pandemic and corresponding federal legislation, non-network
claims as a result of network inpatient admissions, non-network
claims for care in which TRICARE Policy allows delivery from network
or non-network providers without referral or application of the
POS option, and non-network claims when a TRICARE Prime active duty
service member is directed to a non-network provider even though
there is an appointment available to a network provider within access
to care standards.
• 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 The contractor
shall process to completion 98% of retained claims
and adjustment claims within 30 days
from the date of receipt.
1.4.1.2 The contractor
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 prohibits
a contractor from retaining a claim for external development.
1.4.2
Retained
and Excluded Claims
The
contractor shall process 100% of all claims (both
retained and excluded, including adjustments), to
completion within 90 days unless the
Government specifically directs the contractor to continue pending
a claim or group of claims.
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 days.
The contractor shall have an updated beneficiary processed claims
history and deductible file available and accessible within one business
day 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 contractor
shall not allow the absolute value of the payment
errors to exceed 2% of the total billed
charges for the first two option periods. In all remaining option
periods, the contractor shall not allow the
absolute value of the payment errors to exceed
1.75% of the total billed charges.
1.6.2 Claim
Occurrence Errors
The contractor
shall not allow the TED occurrence error rate to exceed
3% for all types of TEDs.
1.7 TEDs
- Timeliness
• The
contractor shall transmit 100% of initial submission
vouchers/batches to DHA within five days
of the date of the batch/voucher create date.
• The
contractor shall correct and return to DHA 85% of
all unprocessable vouchers/batches, including but not limited to,
out-of-balance conditions and invalid header record information within
20 days of the date the invalid data
was transmitted to the contractor by DHA.
• The
contractor shall correct and return to DHA 100% of
unprocessable vouchers/batches within
30 days of the date the invalid data
was transmitted to the contractor by DHA.
• The
contractor shall correct and resubmit to DHA 99.5%
of all vouchers/batches having TEDs (initial submissions, resubmissions,
and adjustment/cancellation submissions) failing the edit system within
30 days after the errors and rejected
TEDs were transmitted to the contractor by DHA. The contractor
shall include all TEDs rejected on the voucher/batch
in question in the resubmission.
• The
contractor shall correct and resubmit to DHA 100%
of all remaining vouchers/batches having TEDs failing the edit system within
45 days after the errors and rejected
TEDs were transmitted to the contractor by DHA. The contractor
shall include resubmission data shall contain all
TEDs rejected in the voucher/batch in the resubmission.
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 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.
2.0 Management
2.1
Filing
2.1.1 The
contractor shall file all hard copy, microform copies and digital/optical
disk imaging of claims/adjustment claims, with attached documentation
by Internal Control Number (ICN) and by state or contract number
within five days after they are processed
to completion. The contractor shall maintain the claim
and all supporting documents in hard
copy, microcopy, or digital image or optical disk.
2.1.2 The
contractor shall make provisions
for
appropriate retention and disposition of files in accordance with
the Federal Records Act and DHA instructions (see
Chapter 9).
2.2 Availability Of Information
The
contractor shall ensure information required for
appropriate responses to inquiries, including but not limited to
claim files, appeals files, previous correspondence and check files are retrievable
and forwarded within five business days following
a request for the information.
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
The
contractor shall stamp all routine written inquiries with
the actual date of receipt within three business days 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 days of receipt;
• Ninety-seven percent (97%)
within 30 days of receipt; and
• One hundred percent (100%)
within 45 days of receipt.
3.2 Priority Written Inquiries
(Congressional, ASD(HA), And DHA)
The contractor
shall stamp all priority written inquiries with
the actual date of receipt within three business days 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 days of receipt.
• One hundred percent (100%)
within 30 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 contractor
shall ensure the following levels
of service are 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
The contractor
shall process to completion 100% of requests for
expedited preadmission/preprocedure reconsiderations within
three business 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 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 days; and
• One hundred percent (100%)
within 60 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 days of receipt;
and
• One hundred percent (100%)
within 60 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
The contractor
shall process to completion 100% of contractor determinations
reversed by the appeals process within
21 days of receipt.
5.0
Grievances
The
contractor shall stamp all written grievances with
the actual date of receipt within three business days of
receipt in the contractor’s custody. The contractor shall provide
interim written response by the 30th day
after receipt for all grievances not processed to completion by
that date. The contractor shall ensure the interim
response includes an explanation for
the delay and an estimated date of completion. The
contractor shall process to completion 95% of all
grievances within 60 days from
the date of receipt.
6.0 Potential Duplicate Claim Resolution
6.1 The contractor shall use 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, the Government will measure contractor performance 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. The
Government will use the Performance Standard Report
generated by the DCS to determine contractor compliance
with this standard (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 business 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. The
contractor shall apply offsets 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) shall note that a check is being
issued to the beneficiary or provider on a priority basis and the
approximate date payment is expected.