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Chapter 1, Section 2, paragraph 4.0 are superseded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-In8.6.1 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.