1.0 Provider Networks
1.1 The contractor shall establish
an adequate network of providers in accordance with access standards
outlined in
Chapter 5, Section 1 and 45 Code of Federal
Regulations (CFR) 156.230, with minimal impact to beneficiaries.
Provider network development shall be completed no later than 30 days
prior to the start of health care delivery (SHCD). The contractor
shall establish an adequate network of providers for Prime Service
Areas (PSAs)
, Base Realignment and Closure (BRAC)
sites, and non-PSAs in the Region. For the purposes
of assessing adequacy, standards shall apply to all PSAs in the region.
1.2 The
contractor shall ensure the network has the capability and capacity
to permit each beneficiary enrolled in TRICARE Prime, to enroll
to a civilian Primary Care Manager (PCM) prior to the start of Option
Period 1 and residing outside of PSAs under this contract to enroll
to a PSA PCM, provided the beneficiary resides less than 100 miles
from an available network PCM in the PSA and waives both primary
and specialty care travel time standards. Beneficiaries enrolled
in Prime to a civilian PCM prior to the beginning of Option Period
1 who reside outside of PSAs under this contract and are 100 miles
or more from an available PCM in the PSA network, shall not be permitted
to continue their enrollment.
1.3 The
contractor shall ensure TRICARE Select access standards for appointments
for health care that meet or exceed those of high-performing health
care systems in the United States. The contractor shall utilize
sizing models to establish network contracting targets sufficient
to support the program’s access standards and network expansion
that meets or exceeds the TRICARE Select requirement by January
1, 2018. See Chapter 5, Section 1.
1.4 The contractor shall ensure
accurate and complete provider information is entered into contractor
and Government automated provider files that interface directly
with the Defense Enrollment and Eligibility Reporting System (DEERS),
contractor medical management systems, and supporting medical management
systems identified by the Government not later than 30 days prior
to SHCD.
1.5 The contractor shall comply
with the Contract Data Requirements List (CDRL) requirements for providing
the contractor’s approach for meeting Access to Care requirements.
2.0
Execution
Of Agreements With Contract Providers
2.1 All
contract provider agreements shall be executed, and loaded to the
incoming contractor’s system, 60 calendar days prior to the SHCD,
or at such other time as is mutually agreed between the contractor
and the Defense Health Agency (DHA).
2.2 The
incoming contractor shall begin reporting on network adequacy on
a monthly basis during the transition.
4.0 Provider Certification
4.1 The outgoing contractor shall
transfer the provider certification documentation to the incoming
contractor. The incoming contractor shall limit certification actions
to new providers and shall verify a provider’s credentials once,
upon application to become a certified provider.
4.2 The contractor shall conduct
an audit, which must include either 5% or 50, whichever is less,
of all prime contractors’ and subcontractors’ individual network
provider credentialing and privileging files to ensure that information
is appropriately verified. The audit shall be completed prior to
the SHCD. Thirty calendar days prior to the audit, the contractor
shall invite the Director, TRICARE Regional Offices (TROs), or for
the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)
and the Contracting Officer’s Representative (COR) to monitor and/or
participate in the audit. Not less than 85% of the audited files
shall be in full compliance with all provider file requirements.
Within five business days of the completion of the audit’s provider
file review, the contractor shall submit to the Procuring Contracting
Officer (PCO) and the Director, TROs, or the TDEFIC COR, a written
Corrective Action Plan (CAP), which addresses all credentialing
and privileging files not in full compliance. Within 30 calendar days
after completion of the audit’s provider file review, the incomplete
or incorrect files shall be corrected to full compliance.
4.3 Provider Certification File
No
later than 30 days after contract award and on a monthly basis until
the SHCD, the outgoing contractor shall provide the incoming contractor
with copies of all provider certification files.
4.4 Phase-Out Of The Contractor’s
Provider Network, TRICARE Service Centers (TSCs) (TRICARE Overseas
Contract Only), And Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM) Agreements
4.4.1 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/eMSM 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, resource sharing agreements,
equipment, telephones and all other functions having an impact on
the MTFs/eMSMs.
4.4.2 Within
15 calendar days of the Transitions Specifications Meeting the outgoing
contractor shall draft and submit a revised plan for transition
of the MTF/eMSM interfaces. Resolution of differences identified
through the coordination process must be accomplished in collaboration
with the Transition Monitor appointed by DHA and according to the
guidelines in the transition schedule.
4.4.3 The
outgoing contractor shall ensure a Health Care Finder (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 (TRICARE overseas contract
only) on the 40th calendar day prior to the SHCD and establish a
centralized HCF function.
4.4.4 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.
4.4.5 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 liability. Beneficiary inquiry lines will continue
to be staffed as defined in the contract. In general, the outgoing
contractor shall maintain adequate toll-free line coverage to ensure
that the blockage rate does not exceed the blockage rate on the
contractor’s most critical private or other Government business
access line.
5.0 Performance Readiness Validation
(PRV)/Performance Readiness Assessment And Verification (PRAV)
During
transition, the incoming contractor’s performance readiness status
regarding provider networks will be subject to PRV/PRAV reviews
as described below.
5.1 Provider
Network PRV
5.1.1 The
contractor shall validate they have established an adequate network
of providers for all PSAs in the region. The contractor will produce
evidence of network adequacy for PCMs, Behavioral Health (BH) providers,
specialty care providers, and health care facilities through comparison
of the number of signed network agreements and the contractor’s
target in their Network Implementation Plan. The contractor shall
validate that signed providers meet credentialing documentation requirements.
For the purposes of assessing adequacy, the validation shall assess
all PSAs in the region individually and not the region as whole.
5.1.1.1 Two hundred and forty days
prior to SHCD, the contractor shall finalize network modeling and
submit their Network Implementation Plan. Interim self-assessment
reports will be provided to the Government at 30 day intervals following
submission of the Network Implementation Plan.
5.1.1.2 Sixty days prior to SHCD, the
contractor shall have completed provider network development including
completion of provider agreements and credentialing.
5.1.2 The contractor shall validate
accurate and complete provider system loads for PCMs and BH providers.
The contractor will develop “load file completion reports” which
compare the percentage of providers loaded into the requisite systems
with the number of providers required by the contractor’s Network
Implementation Plan. The reports shall include the contractor’s
accuracy attestation to the Government regarding the total number
of provider system loads by category (PCMs and BH providers) and
the percentage of records loaded that meet the scheduled accuracy
threshold listed below in all data fields. Contractor validation
goals shall, at a minimum, meet the following:
• Fifty
percent (50%) of PCMs and BH providers loaded no later than 120
days prior to SHCD at a 90% accuracy rate.
• Seventy-five
percent (75%) of PCMs and BH providers loaded no later than 90 days
prior to SHCD at a 90% accuracy rate.
• One hundred
percent (100%) of PCMs and BH providers loaded no later than 60
days prior to SHCD at a 95% accuracy rate.
The
Government will consider exceptions to the 100%/60 day requirement
in medically underserved areas.
5.1.3 The
contractor shall validate accurate and complete specialty provider
(other than BH providers) and health care facility system loads.
The contractor will develop “load file completion reports” which
compare the percentage of specialty providers and facilities loaded
into the requisite systems with the number of specialty providers
and facilities required by the contractor’s Network Implementation
Plan. The reports shall include the contractor’s accuracy attestation
to the Government regarding the total number of system loads by
category (specialty providers and facilities) and the percentage
of total records that meet the scheduled accuracy threshold listed
below in all data fields. Contractor validation goals shall, at
a minimum, meet the following:
• Fifty
percent (50%) of specialty care providers and health care facilities
loaded no later than 120 days prior to SHCD at a 90% accuracy rate.
• Seventy-five
percent (75%) of specialty care providers and health care facilities
loaded no later than 90 days prior to SHCD at a 90% accuracy rate.
• One hundred
percent (100%) of specialty care providers and health care facilities loaded
no later than 60 days prior to SHCD at a 95% accuracy rate.
The
Government will consider exceptions to the 100%/60 day requirement
in medically underserved areas.
5.1.4 The
contractor shall validate the completeness and accuracy of the online
directory of network providers. The contractor shall provide a time
line for completing the online provider directory and develop validation
reports which compare the number of network providers and facilities
who have been entered in the online directory to the total number
of network providers and facilities required by the contractor’s
Network Implementation Plan Validation reports shall begin 120 days
prior to SHCD and continue at 30 day intervals according to the
time lines and scheduled accuracy thresholds listed below, until
the complete provider directory is online and operational 60 days
prior to SHCD at a 95% accuracy rate. Accuracy calculations will
be based on each data field as opposed to each record for each PSA.
Contractor validation goals shall, at a minimum, meet the following:
• Fifty
percent (50%) of network providers and health care facilities entered
no later than 120 days prior to SHCD at a 90% accuracy rate.
• Seventy-five
percent (75%) of network providers and health care facilities entered
no later than 90 days prior to SHCD at a 90% accuracy rate.
• One hundred
percent (100%) of network providers and health care facilities entered
no later than 60 days prior to SHCD at a 95% accuracy rate.
• Complete
provider directory online and operational 60 days prior to SHCD
at a 95% accuracy rate.
The Government will consider
exceptions to the 100%/60 days prior to SHCD requirement in medically
underserved areas.
5.2 Provider
Network PRAV
5.2.1 The
contractor shall comply with the Government’s approach for assessment
and verification of the contractor’s performance readiness regarding
provider networks as described above. If, after review, the Government
finds the contractor’s performance readiness for claims processing
to be deficient, the contractor must submit a detailed mitigation
plan no later than 10 business days following the Government’s findings.
5.2.2 Specific PRAV activities, assessment
techniques, and performance readiness thresholds will be identified
by the Government during the Transition Specification Meeting.