Skip to main content

Military Health System

Utility Navigation Links

WEEKEND MAINTENANCE: The maintenance outage is scheduled for April 20th at 6:00am EST ending NLT Sunday, April 21st at 11:59pm Eastern EST. The TRICARE Manuals web site may be available intermittently during this period but it's usage is not recommended.

TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Medicare Eligible Program (TMEP)
Chapter 20
Section 2
TRICARE Medicare Eligible Program (TMEP) Transition
Revision:  C-108, May 18, 2022
The transition requirements in Chapter 2 shall not apply to the TMEP contractor.
1.0  Contractor Transition-in
1.1  Management And Administration
1.1.1  Integrated Master Plan (MP)/Integrated Master Schedule (IMS)
1.1.1.1  The contractor shall submit an IMP/IMS 10 calendar days after award as identified by DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the contract, to allow Government oversight of transition progress. The contractor’s IMP shall demonstrate that the contract transition is structured to provide a balanced technical approach, to minimize and control risk, to accomplish up-front summary planning and commitment, and to provide a basis for subsequent detailed planning. The contractor shall ensure the IMP includes milestones and measurable indicators that can be used to evaluate the contractor’s satisfactory progress toward being fully capable to enable the start of service performance under this contract.
1.1.1.2  The contractor shall identify an individual responsible for transition management who will serve as the single point of contact for the Government for all transition activities. This individual will be the overall coordination point for the management of the IMP/IMS and coordinate and integrate interdependencies with the outgoing contractor and other entities associated with the transition of the contract.
1.1.2  Transition Specifications Meeting
The contractor shall attend a two to four day meeting with the Defense Health Agency (DHA) within 15 days following contract award. This meeting is for the purpose of developing a schedule for phase-in and phase-out activities. DHA will notify the contractor(s) as to the exact date and location of the meeting. The contractor shall ensure its representatives have the experience, expertise, and authority to provide approvals and establish project commitments on behalf of their organization.
1.1.3  Interface Meetings
1.1.3.1  Within 30 days from contract award, the incoming contractor shall arrange meetings with Government and external agencies to review requirements for the establishment of connectivity with Government systems, applications necessary to meet the requirements of this contract and coordination of operations. The contractor shall include the DHA Program Office representatives in these meetings.
1.1.3.2  The incoming contractor’s Facility Security Officer (FSO) shall attend a meeting with DHA Personnel Security Branch (PSB) to review Personnel security Requirements and the procedures for requesting background checks and Common Access Cards (CACs) in accordance with the TRICARE Systems Manual (TSM), Chapter 1, Section 1.1. The contractor shall ensure the FSO undergoes the required background check and obtains the necessary trustworthiness certification (Automated Data Processing/Information Technology (ADP/IT)) prior to approving requests for the remaining staff in the incoming contractor’s organization.
1.1.3.3  The contractor shall submit to DHA, within 15 days following the interface meetings, a revised IMP/IMS which incorporates the results of the Transition Specifications and interface meetings.
1.1.3.4  The contractor shall document interface meetings with formal minutes and submit them in accordance with the Incoming Weekly Status Reporting, CDRL located in Section J of the contract.
1.1.4  Transition-In (Phase-In) Weekly Status Reporting
The incoming contractor shall submit a weekly status report of the transition schedule progress, identifying schedule modifications and impacts to DHA beginning the 20th calendar day following “Notice of Award” by DHA through the 180th calendar day after the start of services delivery in accordance with the CDRL (or as directed by the Contracting Officer (CO) based on the status of the transition and other operation factors).
1.1.5  Memorandum of Understanding (MOU) with TRICARE Contractors
1.1.5.1  Within 60 calendar days of contract award, the incoming contractor shall meet with and establish an MOU with DHA Communications, in accordance with the CDRL. The Government will ensure the MOU includes, but is not limited to, the review and approval process for educational materials, the identification of desired educational materials required by either DHA or other DHA contractors, the process for requesting additional educational materials, and the ordering and bulk shipment of materials. The contractor shall agree to make the MOU effective within 30 days of the meeting. The contractor shall coordinate the content of the MOU with the CO and the Contracting Officers Representative (COR).
1.1.5.2  Within sixty calendar days prior to the start of services delivery, the incoming contractor shall have executed a MOU with the other TRICARE contractors (Managed Care Support, TRICARE Overseas, and Pharmacy). The contractor shall ensure the MOU includes, but is not limited to, provider file update coordination, beneficiary history transfers, customer service coordination and marketing/education coordination in accordance with the CDRL.
1.1.5.3  Within thirty calendar days prior to the start of services delivery, the incoming contractor shall execute a MOU with the TRICARE Claims Review Contractor for safe, secure, and positive electronic transmittal of claims processing documentation/information in accordance with the CDRL.
1.1.6  Guidelines, Desk Instructions, and Reference Materials
The incoming contractor shall develop processing guidelines, desk instructions/user’s manuals and reference materials for internal use, at least 60 calendar days prior to the start of services delivery. The contractor shall make these available for Government review. The contractor may use electronic versions.
1.1.7  Bank Accounts
The contractor shall establish bank accounts in accordance with Section G, not later than 60 calendar days prior to the start of services delivery.
1.2  Systems Development And Testing
1.2.1  User Access Requirements
The incoming contractor shall ensure personnel complete appropriate background and security checks in accordance with the TSM, Chapter 1.
1.2.2  National Institute of Standards and Technology (NIST) Compliance
The incoming contractor shall provide certification of compliance with the National Institute of Standards and Technology (NIST) Compliance based Information Assurance (IA) program identified in 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.
1.2.3  Connectivity Requirements
The incoming contractor shall collaborate with the Government to establish the required interfaces with Government systems and applications. The contractor shall complete the submission of required forms (e.g., Business to Business Questionnaire, DD Form 2875, etc.) in accordance with the TSM, Chapter 1.
1.2.4  Data Transmissions Start Up
1.2.4.1  The DHA will coordinate Business to Business (B2B) Gateway for all contractors. DHA will also coordinate integration testing of the connectivity and data transmission.
1.2.4.2  At the start-up planning meeting, the incoming contractor on the telecommunication network shall provide DHA the name, address, and telephone number of the person who will serve as a technical Point of Contact (POC). The contractor shall also provide a separate computer center (Help Desk) number to DHA that the DHA computer operator can use for resolution of problems related to data transmissions.
1.2.5  File Conversions And Testing
During the period between the date of award and start of services delivery, the incoming contractor shall, pursuant to the IMP/IMS, meet the following contractor file conversions and testing requirements.
1.2.5.1  DHA will conduct System Integration testing to validate the contractor’s internal interfaces to each of the TRICARE Military Health Systems (MHS) Information Management/Information Technology (IM/IT) systems and applications. The test will verify the contractor’s system integration, functionality, and implementation process.
1.2.5.2  The contractor shall coordinate DMDC data file conversion and testing activities with the Government and submit required documents (Test Plan/Scenarios) within the time frames established during the systems interface meetings but no later than (NLT) 30 days following the Systems Integration Interface Meeting.
1.2.5.3  The contractor shall prepare and complete Integration Testing 45 days prior to the start of services delivery.
1.2.5.4  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 Manager. The testing coordinator is responsible for contractor testing preparations, coordination of tests, identification of issues and their resolution, and verification of test results. The contractor Testing Coordinators shall use a Government provided web application to report and track issues and problems identified during integration testing.
1.2.6  Transaction Testing
In the absence of the inclusion of testing requirements in updated Health Insurance Portability and Accountability Act (HIPAA) legislation, the contractor shall comply with testing requirements in accordance with the CO direction. At a minimum, testing shall include the following:
1.2.6.1  The contractor shall test its capability to create, send, and receive compliant transactions. The contractors shall provide written evidence (e.g., certification from a transaction testing service) of successful testing of their capabilities to create, send, and receive compliant transactions to the contracting offices NLT 60 days prior to the start of services delivery.
Note:  Where failures occur during testing, the contractor shall make necessary corrections and re-test until a successful outcome is achieved.
1.2.6.2  The incoming contractor shall test their capability to process standard transactions. The contractor shall ensure this testing is “cradle-to-grave” from receipt of the transactions, through processing, and completion of all associated functions including creating and transmitting associated response transitions. The contractor shall ensure its testing involves the receipt and processing of claims transaction and submission to and acceptance by the DHA of TRICARE Encounter Data (TED) records and the creation of contract compliant electronic Explanation of Benefits (EOB). The contractor shall complete “cradle-to-grave” testing NLT 30 days prior to the start of services delivery.
1.2.7  TED Testing
The incoming contractor shall demonstrate the ability to successfully create and submit all TED record types and TEPRVs NLT 30 days prior to the start of services delivery. This includes, but is not limited to, adjustment, denial and cancellation records.
1.2.8  Non-Claims Systems
Approximately 60 calendar days prior to the initiation of services delivery under TMEP, DHA or its designees will review the non-claims processing systems and the telecommunications interconnections between these systems. The contractor shall demonstrate that its system(s) capabilities and DHA will determine whether the systems satisfy the requirements of TRICARE as otherwise provided in the contract. The contractor demonstration shall include the telecommunications links with DHA and DEERS. The contractor shall effect any modifications required by DHA prior to the initiation of services delivery under TMEP.
1.3  Customer Service
1.3.1  Call Center
1.3.1.1  The incoming contractor shall ensure its customer service personnel are fully trained and knowledgeable about TMEP and the TRICARE program and are able to accurately answer customer inquiries at the start of services delivery.
1.3.1.2  Prior to the start of services delivery, the contractor shall ensure all incoming contractor customer service personnel attend training on military culture and life. The Government will provide the training materials.
1.3.1.3  The contractor shall demonstrate its successful implementation and operation of its Interactive Voice Recognition System to DHA approximately 60 calendar days prior to the start of services delivery.
1.3.2  Mailings
1.3.2.1  The contractor shall prepare a mailing to all Congressional offices by the 45th calendar day prior to the start of services delivery according to the specifications of the official transition schedule. The contractor shall submit the proposed mailing to the CO and the COR for review, and to DHA Communications for approval NLT 90 calendar days prior to the start of services. The contractor shall ensure the mailing discusses any contractor unique processing requirements and any other needed information dictated by the official transition schedule.
1.3.2.2  The contractor shall mail an introductory letter to all beneficiary households, who had claims activity in the previous 12 months, NLT 45 days prior to the start of services delivery.
1.3.3  Web-Based Services And Applications
The contractor shall demonstrate successful implementation and operation of its web-based capabilities as described in the contract, approximately 60 calendar days prior to the start of services delivery.
1.4  Claims Processing
1.4.1  Claims Processing And Operations
The incoming contractor shall process claims based on the claim date of receipt at the start of services delivery.
1.4.2  Medicare Crossover Claims
1.4.2.1  NLT 60 calendar days prior to the start of the service delivery, the incoming contractor shall establish and test a trading partner agreement with the Medicare Benefits Coordinator Recovery Contractor (BCRC) and have it in place at the start of services delivery to receive claims.
1.4.2.2  NLT 60 days prior to the start of services delivery, the contractor shall demonstrate to DHA successful receipt and testing of electronic claims batches from Medicare for TRICARE processing.
1.4.3  Contractor File Conversion And Testing
The incoming contractor shall complete initial conversion and testing of all Automated Data Processing (ADP) files (e.g., provider files, beneficiary history files, and claim history files) NLT 30 calendar days following receipt of the files from the outgoing contractor.
1.4.4  Receipt of Outgoing Contractor’s Shipment of History Updates and Dual Operations
1.4.4.1  Beginning with the 120th calendar day prior to the start of services delivery and continuing after the start of services delivery until all pertinent claims received by the outgoing contractor have been processed, the incoming contractor shall convert the weekly shipment of the beneficiary history and deductible file updates from the outgoing contractor files within two business days following receipt. The contractor shall validate these files before use. The contractor shall perform tests for claims, update of catastrophic cap, and duplicate claims within two business days following conversion. The incoming contractor shall resolve issues with the outgoing contractor. The incoming contractor shall inform the DHA COR of all issues identified within two business days and provide the problem resolution. Following the start of services delivery, the incoming contractor shall load these files to history and use them for claims processing on the first processing cycle following the check for duplicate claims.
1.4.4.2  During the period after the start of services delivery when the incoming contractor and the outgoing contractor are processing claims, both contractors shall maintain close interface on history update exchanges and provider file maintenance. During the first 60 calendar days of dual operations, both contractors shall exchange beneficiary history updates with each contractor’s claims processing cycle run. Thereafter, both contractors shall ensure the exchange is not less than twice per week until the end of dual processing period.
1.4.5  Prior Authorizations
The incoming contractor shall honor outstanding prior authorization issued by the outgoing contractor, covering care through 60 days after the start of services delivery under the incoming contract, in accordance with the outgoing contractor’s existing practices and protocols, within the scope of the TRICARE program and applicable regulations or statutes.
1.4.6  Duplicate Claims System (DCS)
1.4.6.1  Incoming and Outgoing Contractor Requirements
1.4.6.2  The incoming contractor shall access the web-based DCS via the Patient Encounter Processing and Reporting (PEPR) Portal in accordance with the TSM, Chapter 4 and ensure the connection is tested and accessible.
1.4.6.3  The contractor shall participate in Government furnished DCS training and schedule training per the IMP/IMS.
1.4.6.4  The Government and incoming contractor shall determine together the date when the incoming contractor will assume full responsibility for resolving all existing potential duplicate claim sets from the outgoing contractor (including completing existing recoupments), and for all new potential duplicate claim sets, during transition meetings. The incoming contractor shall add the date to the transition plan/schedule.
1.4.6.5  During transition, the Government will provide DCS training to the incoming contractor. Training will occur between 120 days prior to the start of services delivery and not later than 60 days following the start of services delivery. The incoming contractor shall coordinate training needs in accordance with the transition plan/schedule. The contractor shall meet all user access requirements prior to the initiation of training.
1.4.6.6  The incoming contractor shall begin using the DCS to resolve identified potential duplicate claim sets “owned” by the incoming contractor 120 days following the start of services delivery.
1.4.6.7  The incoming contractor shall begin processing potential duplicate claim sets transferred from the outgoing contractor 150 days following the start of services delivery.
1.4.6.8  The incoming contractor shall identify at least one individual to serve as the DCS POC. The contractor DCS POCs shall be individuals who are, or will be, trained in the use of the DCS, and who is able to perform the required research and determine whether a particular claim is within their processing jurisdiction. The contractor shall provide the name(s), title(s), business address (es), and business telephone number(s) of their DCS POCs to the CO, with courtesy copies to the Contracting Officer Representative (COR) and to the DHA DCS Program Representative. The contractor shall provide the DCS POCs to the CO NLT two weeks prior to the implementation of the DCS.
1.4.6.9  DHA will provide each contractor with the list of all DCS POCs. Whenever a new contract is awarded, DHA will notify all contractors of the new contractor’s DCS POC. Once the initial listing is provided to the contractors, each contractor shall maintain the listing and keep DHA and the other contractors informed of any changes.
1.4.6.10  In accordance with the Financial Procedures in the Transition Plan, the contract, and the TRICARE Operations Manual (TOM), the outgoing contractor shall package and forward to the incoming contractor, refund checks received and offsets taken for recoupments associated with duplicate claims payments and recoupment files associated with in progress duplicate claim recoupment 120 days following the start of services delivery.
1.4.6.11  On the last day of the fourth month following the start of services delivery, or upon direction of the Government, the outgoing contractor shall cease researching Open claim sets and initiating new recoupments associated with duplicate claim payments. The outgoing contractor shall also cease entering refund data and linking adjustment date in the DCS for Pending and Validate claim sets.
1.4.6.12  The outgoing contractor shall move all Open DCS claim sets to Pending, Validate, or Closed status by the last day of TED submissions (as defined by the transition plan).
1.4.6.13  When the outgoing contractor has ceased entering refund and adjustment date on the DCS, the outgoing contractor may receive refunds and/or may submit TED adjustments for claims in Open and Pending sets. In this case, the incoming contractor shall resolve the set without knowing the amount of the refund received by the outgoing contractor.
1.4.6.14  If the actual recoupment amount was zero when the set was transferred from the outgoing contractor, the incoming contractor shall apply the adjustment to the set while leaving the actual recoupment amount as zero dollars. Resolution will result in a Validate status, and the incoming contractor shall explain that the outgoing contractor did not enter the actual recoupment amount.
1.4.6.15  Following the start of services delivery, the DCS will begin displaying identified potential duplicate claim sets that the incoming contractor shall resolve. The incoming contractor shall begin using the DCS to resolve potential duplicate claim sets in accordance with the TSM, Chapter 4 and the IMP/IMS requirements.
1.4.6.16  The incoming contractor shall assume full responsibility for resolving all existing potential duplicate claim sets from the outgoing contractor (including completing existing recoupments) and for all new potential duplicate claim sets as agreed upon during the transition meeting.
1.5  Other Transition Requirements
1.5.1  Performance Assessment Reporting Submissions
1.5.1.1  The contractor shall submit all deliverables to DHA via the E-Commerce Extranet unless otherwise directed by the CDRL. The contractor shall access the system via the Internet through a workstation browser and a static Internet Protocol (IP) address. The application is “thin client” meaning that the contractor does not need to install software on the client workstation and no software is downloaded into the browser. Java script and cookies need to be enabled in the browser to use the application. The application is best viewed at a resolution of 1024 x 768 pixels in an Internet Explorer (IE) browser (Version 8 and higher). Other browsers such as Firefox and Chrome are not supported. The contractor shall access the system using the Secure Socket Layer (SSL) protocol (https://) and the system is protected by individually assigned user name and password or CAC.
1.5.1.2  The contractor shall request access to the Extranet via the E-Commerce User Access Form-External which the Government will provide to the contractor. The Government grants users access to deliverables at the contract level. Deliverables submitted by one contractor are not accessible to any other contractor.
1.5.1.3  The contractor shall submit deliverables that provide data for measuring objective requirements. Details for reporting are identified in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the contract.
1.5.1.4  The incoming contractor shall schedule initial training on deliverable submission within 30 calendar days after award. The Government will provide additional training for new users throughout the contract upon contractor request. The Government will provide technical support during the business week. The Government will provide a POC for access and deliverable submission during initial training.
1.5.2  Program Integrity
1.5.2.1  The incoming contractor shall receive case files and documentation regarding all open program integrity cases from the outgoing contractor NLT 30 days from the start of services delivery. The incoming contractor shall work with the DHA Program Integrity Office (PI) to ensure seamless continuity of oversight of these cases. This shall include any open leads under development, proactive action items, etc., and not limited to cases.
1.5.2.2  The incoming contractor shall develop and maintain standard operating procedures relevant to Chapter 13. The contractor shall provide one complete set of these materials to the Government on the first day of service delivery, as required by the corresponding CDRL, with updates provided as changes occur.
1.5.3  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).
1.5.4  Records Management
The incoming contractor’s Records Management liaison shall attend the first available DHA provided records management training following contract award in accordance with Chapter 9.
1.5.5  Recoupments/Overpayments
1.5.5.1  The incoming contractor and DHA, Office of General Counsel (OGC), Claims Collection Section (CCS), shall receive the designated cases from the outgoing contractor NLT 30 days after the start of services delivery. The incoming contractor shall reflect the number of cases and the amount of the outstanding debt received from the outgoing contractor on the next monthly Accounts Receivable Report following the date of transition. (The details for content and submission of this report are contained in the CDRL).
1.5.5.2  The incoming contractor shall receive cases greater or equal to $110 and that are less than 12 months old. The incoming contractor shall manage these cases 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, and CCS.
1.5.5.3  The incoming contractor shall continue to monitor and manage the VA overpayments in accordance with Chapter 10, Section 4.
1.5.5.4  The incoming contractor shall receive court ordered restitution cases from the outgoing contractor. The incoming contractor shall continue to collect whatever payments are forthcoming and advise the probation officer when a payment is missed, in accordance with Chapter 10, Section 5.
1.5.6  Appeals And Hearings
1.5.6.1  The incoming contractor shall develop and maintain appeals processing guidelines, desk instructions, and reference materials relevant to Chapter 12 and Chapter 11, Section 8. The incoming contractor shall provide one complete set of these materials to the Government as required by the corresponding CDRL, with updates provided as changes occur.
1.5.6.2  The incoming contractor shall assume responsibility for processing new reconsiderations received on and after the start of services delivery.
2.0  Contractor Transition-Out
2.1  Management And Administration
2.1.1  Transition Specifications
2.1.1.1  The outgoing contractor shall attend a two to four day meeting as indicated in paragraph 1.1.2.
2.1.1.2  The outgoing contractor shall provide a proposed phase-out plan at the Transition Specifications Meeting.
2.1.1.3  The outgoing contractor shall identify an individual responsible for transition management who will serve as the single point of contact for the Government for all transition activities.
2.1.2  Transition-Out (Phase-Out) Weekly Status Reporting
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 CO to discontinue. The contractor shall comply with specifications of the official transition schedule.
2.1.3  Provide Information
The outgoing contractor shall, upon receipt of written request from DHA, provide to potential offerers 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.
2.1.4  Data
The 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. The outgoing contractor shall provide all files 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 claims processing system.
•  Information about the management of the contract that is not considered, under applicable Federal law, to be proprietary to the contractor.
2.2  System Testing
2.2.1  Common Access Cards (CACs)
The outgoing contractor shall ensure retrieval of CACs as outlined in the TSM, Chapter 1, Section 1.1.
2.2.2  Duplicate Claims System (DCS)
The outgoing contractor shall phase-out the use of the automated TRICARE DCS in accordance with TSM, Chapter 4 and the IMP/IMS.
2.3  Claims Processing
2.3.1  Phase-Out of the Contractor’s Claims Processing Operations
Upon notice of award to another contractor, and during the procurement process leading to a contract award, the outgoing contractor shall undertake phase-out activities described below.
2.3.2  Transfer of Electronic File Specifications
The outgoing contractor shall provide to the incoming contractor, NLT three calendar days following award announcement or upon direction of the CO, electronic copies of the record layouts with specifications, formats, and definitions of fields, and data elements, access keys and sort orders, for the following:
•  Beneficiary History Files.
•  Claims History Files.
•  The TRICARE Encounter Provider Files (TEPRVs).
•  Mental Health Provider Files: The outgoing contractor give the incoming contractor accurate provider payment information on all mental health providers paid under the TRICARE inpatient mental health per diem payment system. This shall include provider name; Tax Identification Number (TIN); 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 contractor shall ensure the providers under the per diem payment system are designated by Medicare, or meet exemption criteria, as exempt from the inpatient mental health unit.
The unit is be identified as the provider under the TRICARE inpatient mental health per diem payment system.
2.3.3  Transfer of ADP Files
By the 15th calendar day following the Transitions Specifications Meeting, the outgoing contractor shall prepare in non-proprietary electronic format and transfer to the incoming contractor or DHA, unless otherwise negotiated by the incoming and outgoing contractors, all specified ADP files (e.g., provider certification and any pricing files, check copies, release of information documents, TPL files, etc.) in accordance with specifications in the official transition schedule and shall continue to participate in preparation and testing of these files until they are fully readable by the incoming contractor or DHA.
2.3.4  Outgoing Contractor Weekly Shipment of History Updates
The outgoing contractor shall transfer to the incoming contractor, in non-proprietary electronic format, all beneficiary history and deductible transactions occurring from the date of preparation for shipment of the initial transfer of such history files and every week thereafter beginning the 120th calendar day prior to the start of services delivery until such a time that all processing is completed by the outgoing contractor in accordance with the specifications in the official transition schedule.
2.3.5  Prior Authorizations
The outgoing contractor shall provide all prior authorizations that cover care spanning the start of services delivery under the new contract or care that could potentially be in the incoming contractor’s services delivery period. The outgoing and incoming contractor shall mutually agree to the date and schedule for transfer of this information.
2.3.6  Transfer of Beneficiary Information
The outgoing contractor shall provide a list of all TMEP special program (ECHO, ICMP-PEC, etc.) and LDT Demonstration beneficiaries to the incoming contractor.
2.3.7  Transfer of Non-ADP Files
The outgoing contractor shall transfer to the incoming contractor all non-Automated Data Processing (ADP) files (e.g., Congressional and DHA completed correspondence files, appeal files, TRICARE medical utilization, and administration files) in accordance with the specifications in the official transition schedule and Chapter 9. The outgoing contractor shall transfer hard copies of the Beneficiary History Files to the incoming contractor or Federal Records Center (FRC) as required by Chapter 9. The outgoing contractor shall provide samples and descriptions of these files to the incoming contractor at the Transition Specification Meeting.
2.3.8  Final Processing of Outgoing Contractor
The outgoing contractor shall:
•  Process to completion all claims, to include adjustments, received during its period of services delivery. The contractor shall complete processing these claims within 180 days following the start of the incoming contractor’s services delivery. The outgoing contractor shall meet all contract standards for these claims.
•  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.
2.3.9  Correction of Edit Rejects
The 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 services delivery.
2.3.10  Termination of Trading Partner Agreement
The outgoing contractor shall terminate their trading partner agreement with the BCRC to ensure receipt of crossover claims concludes with the end of the period of performance.
2.4  Other Outgoing Transition Requirements
2.4.1  Program Integrity
The outgoing contractor shall provide weekly updates, on the outgoing weekly status report, of program integrity case files, including new cases initiated through the end of the outgoing contractor’s contract delivery period. This shall also include active leads and cases under development that have not yet been forwarded to DHA PI. See Chapter 9 for additional information on transferring electronic records.
2.4.2  Records Management
2.4.2.1  The outgoing contractor shall provide an automated indexing system that can be used independently of the contractor’s data system as outlined in Chapter 9, Section 3, in the event of a transition.
2.4.2.2  The outgoing contractor shall maintain a complete set of documentation to transfer to the incoming contractor in the event of a transition. The contractor shall ensure the documentation describes the metadata, how the files are formatted, and other information that will allow DHA or an incoming contractor to efficiently and effectively retrieve the records. If the outgoing contractor does not have an incoming contractor to transfer documentation to, see Chapter 9, Section 4, for additional guidance on records disposal, storage and transfer.
2.4.2.3  Upon direction from DHA, the outgoing contractor shall also be prepared to present the incoming contractor with standard claim images, in Tagged Imaged File Format (TIFF) or searchable Portable Document Format (PDF). Valid alternatives shall be submitted to DHA for review and consideration.
2.4.3  Transfer of Electronic Records
2.4.3.1  During transition, the outgoing contractor shall transfer all DHA electronic records not eligible for destruction along with their associated metadata to the incoming contractor. DHA electronic records suitable for transfer shall be identified through meetings between contractors, the DHA Records Management Officer and the DHA Contracting Office. The outgoing contractor shall develop a process for transferring the data to the incoming contractor that ensures no metadata or their associated record objects are lost in the transition process.
2.4.3.2  The outgoing contractor shall ensure documentation adequately identifies, services, and interprets electronic records designated for storage by DHA and shall transfer the documentation with the records.
2.4.4  Explanation of Benefits (EOB) Record Data Retention and Transmittal
If the outgoing contractor elects to retain the EOB data on a computer record, the contractor shall, 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 CO’s discretion, provide the data and necessary programs to reproduce the EOB in acceptable form and transfer such data and programs to the incoming contractor or to DHA. DHA will be the final authority in determining the form and/or acceptability of the data. See Chapters 2 and 9 for additional information on transitioning electronic EOBs.
2.4.5  Records Disposition
2.4.5.1  The outgoing contractor shall comply with the requirements in Chapter 9, in final disposition of all files and documentation. The outgoing contractor shall include records disposition plan as part of the phase-out plan submitted to DHA at the Transition Specifications Meeting.
2.4.5.2  Once the transition of records and materials has been accomplished, the outgoing contractor shall destroy all copies to include backup data in accordance with 36 CFR Part 1226, “Implementing Disposition”. The contractor shall not dispose or destroy any copies or backup data prior to formal, written notification from the DHA Contracting Office or DHA Records Management Office. The contractor shall provide a formal record of destruction or certificate to the DHA CO and the DHA Records Management Officer documenting what was destroyed, the date(s) destroyed and by whom. The contractor shall include a records disposition plan as part of the phase-out plan submitted to DHA at the Transition Specifications Meeting.
2.4.5.3  In the event that the outgoing contractor does not have an incoming contractor to accept transfer of electronic records, refer to Chapter 9, Section 4, for additional guidance on records disposal, storage, and transfer.
2.4.6  Recoupments/Overpayments
2.4.6.1  The outgoing contractor shall send the designated cases NLT 30 days after the start of services delivery.
2.4.6.2  The outgoing contractor shall submit a credit adjustment to include all amounts recouped up to the point of transition. The outgoing contractor shall ensure its final Accounts Receivable Report reflects the number of cases and the amount of the outstanding debt transferred to the incoming contractor.
2.4.6.3  Installment Cases
The outgoing contractor shall transfer all installment cases to DHA, Office of General Counsel (OGC), CCS. The contractor shall provide a list of all installment cases to be transferred by fax or encrypted email to CCS before transferring the cases.
2.4.6.4  Cases Less Than 12 months
The 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. The outgoing contractor shall write-off cases that do not meet the criteria.
2.4.6.5  Cases Greater Than 12 Months
2.4.6.5.1  The outgoing contractor shall write off cases less than $600 that when combined with other cases do not equal $600 or more, and reported on line A5 of the Accounts Receivable Summary Report (refer to the CDRL).
2.4.6.5.2  The outgoing contractor shall transfer cases greater or equal to $600 to DHA, OGC, CCS. The contractor shall provide a list of all transfer cases to CCS by fax or encrypted email before the cases are transferred.
2.4.6.6  Veterans Affairs (VA) Overpayments
The outgoing contractor shall transfer identified VA Overpayment cases to the incoming contractor in accordance with the transition schedule.
2.4.7  Third Party Recovery
The outgoing contractor shall transfer, in accordance with the transition schedule, court ordered restitution cases to the incoming contractor for continued collection.
2.4.8  Appeals And Hearings
The outgoing contractor shall accept requests for reconsideration, including requests by DHA to reopen a case, received through the end of the outgoing contractor period of performance.
2.4.8.1  Assistance to Incoming Contractor, TRICARE Quality Management Contract (TQMC), and DHA During Transition
During transition, the outgoing contractor or the TQMC shall make available, upon request, individual cases completed during the transition period and not yet transferred to the incoming contractor or TQMC. The outgoing contractor shall not mail the appeal file to the incoming contractor, the TQMC, or DHA later than five business days after receipt of a telephonic, written or fax request from DHA or the incoming contractor during a transition period.
2.4.8.2  Appeal Case Files
Upon request from the incoming contractor, the outgoing contractor shall transfer individual cases completed during the transition period and not yet transferred to the incoming contractor in accordance with Chapter 12.
2.4.9  Cost Accounting
If the outgoing contractor succeeds itself, the contractor shall keep costs related to each contract separate for purposes of contract accountability.
- END -
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery