1.0 General
The contractor shall establish
and maintain sufficient staffing and management support services
and commit all other resources and facilities necessary to achieve
and maintain compliance with all quantitative and qualitative standards
for claims processing timeliness, claims inventory levels, claims
control, and claims accuracy. The requirements below outline minimum
requirements of Defense Health Agency (DHA). Contractors are encouraged
to develop and employ the most effective management techniques available
to ensure economical and effective operation.
2.0 System Additions Or Enhancements
2.1 Implementation of Changes in
Program Requirements
The
contractor shall have the capacity, using either directly employed
personnel or contracted personnel, to maintain and operate all required
systems and to achieve timely implementation of changing program
requirements.
2.2 Maintaining
Current Status of Diagnostic and Procedural Coding Systems (PCS)
Contractors
are required to use the current versions of the updated American
Medical Association Physicians Current Procedural Terminology, 4th
Edition (CPT-4), and the International Classification of Diseases,
9th Revision, Clinical Modification (ICD-9-CM) diagnostic coding
system; and any special codes that may be directed by DHA. Beginning
with dates of service on or after the mandated date, as directed
by Health and Human Services (HHS) for International Classification
of Diseases, 10th Revision (ICD-10) implementation, for outpatient
facility and all non-facility services, and for inpatient facility
charges with discharge dates on or after the mandated date, contractors
will be required to replace the use of ICD-9-CM diagnosis codes
with the current version of the ICD-10-CM and the International
Classification of Diseases, 10th Revision, Procedure Coding System
(ICD-10-PCS) for inpatient hospital procedures. The contractor is
responsible for using the most current codes correctly. That responsibility
includes making any needed revisions required by periodic CPT-4
and ICD-9-CM or ICD-10-CM and ICD-10-PCS updates issued by the publishers.
When updates occur, contractors will be notified of the date the
TRICARE Encounter Data (TED) editing system will be accepting changes
in the codes.
2.3
Zip Code File
The
contractor shall maintain and update an electronic file of all zip
codes using a Government-furnished electronic zip code directory.
The contractor shall incorporate this electronic file in its claims processing
system to determine the validity of a beneficiary or provider zip
code. This directory will be provided by the Government no less
than four and no more than 12 times per calendar year. Updates to the
electronic zip code directory for the purposes of contract modifications,
directed policy actions, and expansion or termination of zip codes
by the U.S. Postal Service (USPS), shall be accomplished at no additional
cost to the Government.
2.4
Updating
And Maintaining TRICARE Reimbursement Systems
The contractor, at no additional
cost to the Government and as directed by DHA shall implement all
policy changes and clarifications to existing TRICARE reimbursement
systems affecting both the level of payment and the basic method
of reimbursement as they apply to current provider categories implemented
at the time of contract award. The TRICARE Reimbursement Manual
(TRM) is the source for instructions and guidance on all existing
reimbursement systems for current provider categories.
3.0 Management Controls
The
contractor shall develop and employ management procedures necessary
to ensure control, accuracy, and timeliness of transactions associated
with operation of their call center, TRICARE Service Center (TSC)
functions (TRICARE overseas contract only), enrollment, authorizations,
provider referrals, claims processing, beneficiary services, provider
services, reconsiderations, grievances, Automatic Data Processing
(ADP), and financial functions. These procedures include such elements
as:
3.1 An automated claims aging report,
by status and location, for the purpose of identifying backlogs
or other problem areas delaying claims processing. At a minimum,
this report must be sorted to enable a count of the total number
of claims pending for a specified length of time, e.g., the time periods
specified in the Monthly Cycle Time/Aging Report.
3.2 An automated returned claims
report counting the number of claims returned by the time periods
specified in the Monthly Cycle Time/Aging Report.
3.3 Procedures to ensure confidentiality
of all beneficiary and provider information, to ensure that the
rights of the individual are protected in accordance with the provisions
of the Privacy Act and the HIPAA and Health and Human Services (HHS)
Privacy Regulation and prevent unauthorized use of DHA files.
3.4 A system to control adjustments
to processed claims which will document the actual date the need
for adjustment is identified, the reason for the adjustment and
the names of both the requesting and authorizing persons. The controls
shall also ensure the accurate and timely update of the beneficiary
history files, the timely and accurate submission of the TED data
and issuance of the proper notice to the beneficiaries and providers
affected by the adjustments.
3.5 A
set of processing guidelines, desk instructions/user’s manuals and
reference materials for internal use. These materials shall be maintained,
on a current basis, for the life of the contract. Desk instructions
shall be available to each employee in the immediate work area.
Reference material such as procedure codes, diagnostic codes, and
special processing guidelines, shall be available to each work station
with a need for frequent referral. Other reference materials shall
be provided in each unit with a reasonable need and in such quantity
as to ensure the ease of availability needed to facilitate work flow.
Electronic versions may be used.
4.0 Quality Control
4.1 The
contractor shall develop and implement an end-of-processing quality
control program which assures accurate input and correct payments
for authorized services received from certified providers by eligible
beneficiaries.
4.2 The
contractor shall have a quality control program consisting of supervisory
review of appeals, grievances, correspondence, and telephone responses.
This must begin by the end of the third month after the start of
health care delivery (SHCD) and be carried out monthly thereafter.
The review shall include a statistically valid sample or 30 records,
whichever is greater, of each of the following: appeals, grievances,
correspondence processed and telephonic responses completed. The
criteria for review shall be accuracy and completeness of the written
or telephonic response, clarity of the response, and timeliness
with reference to the quantitative standards for the processing
of appeals, grievances, and correspondence. Any lack of courtesy
or respect in the response shall also be noted. All findings shall
be documented, provided to DHA Contracting Officer’s Representative
(COR) staff, or authorized auditors, and used in a documented training
program.
4.3 The
quality review program will sample each quarter, a sufficient number
of processed claims and adjustments to ensure the required quality
of adjudication and processing and provide adequate management control.
Claims in the sample shall include all claim types and be selected
randomly, or by other acceptable statistical methods, in sufficient
number to yield at least a 90% confidence level with a precision
of 2%. The sample will be drawn at or near the end of each quarter
from claims completed during the review period. The contractor may
draw the sample up to 15 calendar days prior to the close of the
quarter, but must include claims completed in the period between
the date the sample is drawn and the close of the quarter in the
next quarterly sample. The contractor shall reflect the inclusive processing
dates of the claims in the sample in the report submitted to DHA.
The sampling will begin by the end of the first quarter of processing.
Documentation of the results shall be completed within 45 calendar
days of the close of each contract quarter.
4.4 The contractor shall retain
copies of the reviewed claims, appeals, grievances, correspondence, and
related working documents, in separate files, for a period of no
less than four months following submission of audit results to the
Procuring Contracting Officer (PCO). DHA staff will review the results and
will on a regular basis audit a selected sampling of the audited/quality
review documents. The review may occur at the contractor’s site
or at a location specified by DHA. The contractor shall provide all
documentation supporting this review within 10 calendar days of
a DHA request.
5.0
Staff
Training Program
The
contractor shall develop and implement a formal initial and ongoing
staff training program including training on program updates as
they occur, to ensure a high quality of service to beneficiaries and
providers. Such training shall include mandatory, documented training
in Confidentiality of Patient Records (42 United States Code (USC)
[290dd-3]) requirements (see
Section 5). The
contractor shall not only provide education on these requirements
but must document the personnel files of the staff members who receive
the training. Centralized documentation shall also be maintained
of the training session agendas, identity of attendees, actual dates
and duration of training sessions, etc. The contractor is also responsible
for ensuring that subcontractor staff is fully trained.
6.0 Internal Audits And Management
Control Programs
Using
its corporate internal review capability, the contractor is responsible
for verifying that accounting data are correct, reliable and comply
with all Government accounting standards and requirements. The contractor’s
corporate internal review staff must conduct regular, routine reviews
to ensure proper monitoring in the areas of finance, financial accounting,
internal controls, special checks issued and returned, and selected
history maintenance transactions for possible fraud or abuse.
7.0 Beneficiary Surveys
In
accordance with Department of Defense Instruction (DoDI) 1100.13,
and Health Affairs Policy Memorandum 97-012, surveys of military
members, retirees and their families must be approved and licensed
through issuance of a Report Control Symbol (RCS). Contractors shall
not conduct written or telephonic beneficiary surveys without the
approval of the DHA Decision Support Division (DSD). DHA has an
ongoing survey research and analysis program which includes periodic
population-based and encounter-based surveys of DoD beneficiaries.
The surveys address beneficiary information seeking strategies and
preferences, health status, use of care, satisfaction with military
and civilian care, and attitudes toward TRICARE. The data are collected
at the Prime Service Area (PSA) level and can be aggregated to the
regional level. Regional reports containing PSA data are available
through the Director, TRICARE Regional Offices (TROs)/Program Office.
Contractors shall work with the Director, TROs/Program Offices to
define both their ongoing and special purpose requirements for survey
data. Contractors with special needs not met by an existing instrument
may submit surveys, sampling plans, and cost estimates through the
Director, TROs/Program Office to the DHA, DSD, for approval and licensing.