2.0 DHA Performance Readiness Validation
(PRV)/Performance Readiness Assessment And Verification (PRAV)
During
transition, the incoming contractor’s performance readiness status
regarding claims processing will be subject to PRV/PRAV reviews
as described below.
2.1 Claims
Processing PRV
2.1.1 The
contractor shall validate its ability to process all TRICARE claim
types with a minimum of a 98% accuracy rate no later than 90 days
prior to SHCD. Claims testing shall include multiple claim types
that represent a level of complexity involved in claims for TRICARE
benefits. Validation shall include claims processing at the operational
volume and stress testing at projected claims volumes. The contractor
shall provide validation results, to include test scenarios used,
to the Government within 10 days following conclusion of the contractor’s
validation.
2.1.2 The
contractor will validate its ability to provide timely and accurate
responses to beneficiary and provider claims customer service inquiries
and attest that they meet the following staffing requirements:
• Seventy-five
percent (75%) of beneficiary and provider claims customer service
staffing hired and trained on provider and beneficiary claims customer
service, including internal and external systems interfaces, no
later than 90 days prior to SHCD.
• Eighty-five
(85%) of beneficiary and provider claims customer service staffing
hired and trained on provider and beneficiary claims customer service,
including internal and external systems interfaces, no later than
60 days prior to SHCD.
• Ninety-five
(95%) of beneficiary and provider claims customer service staffing
hired and trained on provider and beneficiary claims customer service,
including internal and external systems interfaces, no later than
30 days prior to SHCD.
2.1.3 The contractor shall validate
it can receive and utilize claims history file transfers from the outgoing
contractor no later than 14 calendar days following receipt of the
files from the outgoing contractor.
2.1.3.1 The contractor shall include
in its validation process a test of a statistically valid number
of records to ensure readability and usability of information. Tests
shall include accessibility to records, accuracy of data, and the
contractor’s ability to use the data to correctly to apply TRICARE
policy, such as time or episode limited benefits.
2.1.3.2 Results must reach a minimum
of 98% accuracy no later than 45 days prior to SHCD. The contractor
shall provide test scenarios as well as testing results to the Government
no later than 45 days prior to SHCD.
2.1.4 Reimbursement rate system applications
validation.
2.1.4.1 The
contractor shall develop tests to ensure reimbursement rate system
applications are correctly loaded and functioning properly. Areas
tested shall include negotiated network discount rates, non-network
rates, and specific reimbursement rates as required by policy (Example:
Sole Community Hospitals (SCHs), Low/High-Volume Mental Health Facilities,
Partial Hospitalization facilities, etc.). Validation shall include
demonstrating a variety of claims scenarios where reimbursement
rate system applications are applied.
2.1.4.2 The contractor shall complete
its reimbursement rate system validation no later than 90 days prior
to SHCD and provide the Government with validation results, to include
test case scenarios used, within 10 days following conclusion of
the contractor’s validation. If, after review, the Government finds
the contractor’s testing or outcomes are deficient, the contractor
shall submit a detailed mitigation plan no later than 14 calendar
days following receipt of the Government’s findings.
2.1.5 Validation that the claims
processing system differentiates between beneficiary categories.
2.1.5.1 The contractor shall validate
that its claims processing system clearly identifies and appropriately
differentiates between beneficiary categories to facilitate claims
processing accuracy by testing a multitude of scenarios with different
beneficiary categories (as specified in the TRICARE Systems Manual
(TSM)) to ensure appropriate application of cost-shares, co-pays
and rates.
2.1.5.2 The
contractor shall complete its system testing no later than 90 days
prior to SHCD with a 95% accuracy rate. The contractor shall complete
its claims processing system differentiation validation no later
than 90 days prior to SHCD and provide the Government with validation
results, to include test case scenarios used, within 10 days following
conclusion of the contractor’s validation. If, after review, the
Government finds the contractor’s testing or outcomes are deficient,
the contractor shall submit a detailed mitigation plan no later
than 10 business days following receipt of the Government’s findings.
2.1.6 Claims and TED records systems
interface validation.
2.1.6.1 The contractor’s validation
shall include developing and executing tests to validate its claims
processing system (Defense Enrollment Eligibility Reporting System
(DEERS)/Defense Manpower Data Center (DMDC), Referrals/Authorizations,
etc.) can process claims in accordance with TRICARE timeliness and
accuracy standards. The contractor’s validation methodology shall
aggressively test system connectivity of its claims processing system
with both internal and external systems in order to ensure timely
and accurate processing of claims. Testing shall include responses
consistent with production volume as well as stress testing.
2.1.6.2 The contractor shall complete
its system testing with Government interfaces and attest to the
contractor’s ability to apply information received from DEERS/DMDC
(beneficiary eligibility, catastrophic cap (CATCAP), family association,
etc.) in a timely and accurate manner, and that they are able to
successfully process TEDs prior to moving to a production environment.
The contractor shall provide its system test plan to the Government
at contract award. Initial testing shall begin no later than three
months following contract award, and the contractor’s claims/TEDs
system interfaces shall be fully operational no later than 60 days
prior to SHCD.
2.1.7 Validation
that the contractor’s claims processing system accurately and appropriately applies
referrals and authorizations.
2.1.7.1 The contractor’s validation
shall include demonstrate its ability to integrate its referrals
and claims systems with the direct care system through CHCS and/or
other Military Treatment Facility (MTF)/Enhanced Multi-Service Market
(eMSM). The contractor shall validate that its claims processing system
is able to accurately and appropriately transfer and apply information.
The contractor shall attest to its ability to achieve a minimum
of 98% accuracy in receiving and applying referrals/authorizations
information received from MTFs/eMSMs and use this information to
correctly process claims.
2.1.7.2 Communication interface trustworthiness
determinations between the contractor and MTFs/eMSMs must be obtained
and operational no later than 120 days prior to the SHCD and all validation
testing shall be completed no later than 60 days prior to SHCD.
2.2 Claims Processing PRAV
2.2.1 The contractor shall comply
with the Government’s approach for assessment and verification of
the contractor’s performance readiness regarding claims processing
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 days 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.