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.