3.1 General
3.1.1 No
later than 60 days prior to the start of services,
the incoming contractor shall demonstrate the ability of its staff
and its automated systems to accurately process all types of TRICARE Pharmacy
(TPharm) claims in accordance with current requirements. This shall be
accomplished through a comprehensive Benchmark test.
3.1.2 On
a mutually agreed upon timeline between the Government and the contractor,
DoD/DHA representatives will conduct a pre-benchmark meeting at
the incoming contractor’s site.3.1.2.1 The
incoming contractor shall provide an overview of their system(s)
and the test process, collect data for use in the benchmark, discuss
the involvement of external systems in the test (e.g., DEERS), and
discuss the dates of the test and information regarding the administration
of the test.
3.1.2.2 At this time,
DHA will provide the test scenarios to the incoming contractor that
are to be used in the development of the test claims.
3.1.2.3 Data
requirements will be coordinated at the pre- benchmark meeting to
ensure that the incoming contractor adequately prepares all files
prior to the benchmark. Electronic transaction requirements will
be discussed to include timing and logistics.
3.1.3 At
this pre-benchmark meeting, the incoming contractor shall be advised
of the logistics of the Benchmark test to include, but not limited
to:3.1.3.1 The number of
DoD/DHA staff who will monitor and evaluate the results of the test;
3.1.3.2 The
amount of time the incoming contractor shall have to process test
claims;
3.1.3.3 The process and
point of contacts for the incoming contractor to use for questions
related to the test scenarios provided by DHA;
3.1.3.4 Space requirements
for the DHA team including access to telephones, computer terminals, and
printers;
3.1.3.5 What reference
documents the incoming contractor shall make available to the DHA
team during the test (e.g., TRICARE Manuals, Explanation of Benefits
(EOB) message codes, reject/denial codes, organizational chart,
personnel directory, etc.).
3.1.4 The incoming contractor shall
demonstrate its ability to conduct eligibility verification and claims
processing functions to include
, but not limited to:
3.1.4.1 Claims control and development;
3.1.4.2 Accessing and
updating DEERS (e.g., Other Health Insurance (OHI), personal contact information,
etc., excluding eligibility status);
3.1.4.3 Calculating cost-shares and
deductibles;
3.1.4.4 Querying and updating internal
and external family and patient deductible and cost-share files
on the Catastrophic Cap and Deductible Data (CCDD) file;
3.1.4.5 Applying utilization review
criteria;
3.1.4.6 Applying correct
benefit design based on the beneficiary category, plan enrollment,
point of service and other factors;
3.1.4.7 Applying overrides
to rejects;
3.1.4.8 Adjusting and canceling previously
processed claims (inside and outside the 10-day window for network
retail pharmacy claims);
3.1.4.9 Producing required output for
paper and electronic transactions.
3.2 Benchmark Procedure
s3.2.1 On
the first day of the Benchmark test, the Government
will hold a brief entrance conference with
the incoming contractor personnel to discuss the schedule of events,
expectations, and administrative instructions.
3.2.2 The
Benchmark test shall consist of up to 1,000 claims, testing a multitude
of claim conditions, including TPharm covered and non-covered services,
eligible and non-eligible beneficiaries, formulary and non-formulary
processing, coordination of benefits, Department of Veterans Affairs
(DVA)/Veterans Health Administration (VHA) claims, Medicaid claims,
etc. The Benchmark test may require up to seven consecutive calendar
days at the contractor’s site(s). The test may also include adjustments
and reversals, and submission of TRICARE Encounter Data (TED) records for
these actions.
3.2.3 The
incoming contractor shall conduct the Benchmark test. The test shall
be comprised of both paper and electronic (batch and Point of Service
(POS)) claim transactions. The incoming contractor shall be required
to create test claims, including prior authorizations and medical
necessity reviews from test scenarios provided to the contractor
by DHA. The incoming contractor shall supplement these test scenarios
with any internal conditions if appropriate for testing, and forward documentation
to the Government.
3.2.4 The
Benchmark test is comprised of one or more cycles or batches of
claims. When more than one cycle is used, each cycle may be submitted
on consecutive days. Each cycle after the initial one shall include
new test claims, as well as claims not completed during preceding
cycles. The Government will determine what aspects of claims processing
will be tested.
3.2.5 The
Government will determine which systems (internal and external)
used by the incoming contractor to process claims will be used in
the Benchmark Test. The Benchmark test shall also include generation
and submission of TED records for every test claim. Incoming contractor compliance
with applicable Health Insurance Portability and Accountability
Act (HIPAA) and security requirements shall be included in the Benchmark
test, as appropriate.
3.2.6 During
the Benchmark test, the incoming contractor shall process the claims
and shall provide output for evaluation by DHA personnel as the
claims are processed to completion. The specific schedule for claims
processing and the procedures for providing the output will be discussed with
the incoming contractor at the pre-benchmark meeting. The
outcome of each test scenario will be evaluated based on documentation
provided and maintained by the incoming contractor, including payer
sheets, benefit design document, interface control documents, etc.
3.2.7 At
the conclusion of the Benchmark test, the Government
may hold an exit conference with the
incoming contractor staff to brief the incoming contractor on all
findings identified during the Benchmark test.
The Government will forward
the initial Benchmark test report to the incoming contractor within 30 calendar
days of the last day of the test. For any claims processing errors
assessed with which the incoming contractor disagrees, a written
description of the disagreement along with any specific references shall be
included with the claims. The incoming contractor shall correct
all findings identified during the Benchmark test no later than 30 days
following the date of the initial report.
3.2.8 Within
seven calendar days of the last day of the Benchmark test, the incoming
contractor shall prepare and submit the initial TED records to DHA.
The Government will notify incoming contractor of
any TEDs failing the DHA edits. The incoming contractor shall make
the necessary corrections and resubmit the TED records until 100%
of the original Benchmark test TEDs
have passed the edits and are accepted by DHA.
3.2.9 The
incoming contractor shall submit the final corrected
TED record to DHA 45 calendar days from the date
of the initial Benchmark test report.
New TEDs need not be generated to reflect changes created from claims
processing corrections. All
TEDs originally submitted for the Benchmark test
claims which did not pass DHA edits shall continue
to be corrected and resubmitted until all edit errors have been
resolved and 100% of the TED records have been accepted by DHA.
3.3 Operational Aspects
3.3.1 The incoming
contractor shall conduct the Benchmark test on
the incoming contractor’s production system(s) or an identical copy
of the production system (i.e., test system). Whichever system is
used for the benchmark, it shall meet
all TRICARE requirements. If the Benchmark
is conducted on the incoming contractor’s production system, the
incoming contractor shall prevent the possibility of any data
being transmitted to other production systems, including inappropriate checks
or EOBs being actually mailed to beneficiaries or providers.
3.3.2 Certain external test systems
and files (e.g., DEERS) are an integral
component of the Benchmark test, and the incoming contractor shall perform
all necessary verifications, queries, etc., according to TRICARE
procedures and requirements. The incoming contractor shall coordinate
through DHA to ensure that direct interface with any required external
test system is established and operational prior to the Benchmark.