3.1 General
3.1.1 No later
than 60 calendar 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 TPharm claims in accordance
with current requirements. This will be accomplished through a comprehensive
Benchmark test.
3.1.2 On a mutually agreed upon timeline
between the Government and the incoming 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 shall 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 shall 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
for 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 (POS)
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-calendar day window
for network retail pharmacy claims);
3.1.4.9 Producing required output for
paper and electronic transactions.
3.2 Benchmark
Procedures
3.2.1 On the first day of the Benchmark
test, a brief entrance conference will be held 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/Veterans Health Administration (DVA/VHA)
claims, Medicaid claims, etc. The benchmark 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 will 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 calendar days.
Each cycle after the initial one will include new test claims, as
well as claims not completed during preceding cycles. All aspects
of claims processing may be tested.
3.2.5 The Benchmark
test may include testing of any and all systems (internal and external)
used by the incoming contractor to process claims. The Benchmark
will also test 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 will 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, an exit conference may be held
with the incoming contractor staff to brief the incoming contractor
on all findings identified during the benchmark. The initial Benchmark
test report will be forwarded to the incoming contractor by DHA
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 must be included with the claims. The incoming contractor
shall correct all findings identified during the Benchmark test
no later than 30 calendar 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 the 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. 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 must 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 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 is expected to
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.
3.3.3 The incoming contractor shall
also conduct high-volume stress testing for retail pharmacy transactions. The
purpose of this stress test is to ensure that proposed systems and
system interfaces are configured to allow for a high volume of transactions
in an acceptable time frame consistent with contract performance
standards.