4.0 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.
4.1 Provider Credentialing PRV
4.1.1 The incoming contractor shall
conduct an audit, which must include either 5% (but not less than
50) or 100 (50% initial files as is available, 50% re-credential
files), whichever is less, of all contractors’ and subcontractors’ network
provider credentialing and privileging files and facility credentialing
files, including: individual providers, facilities, BH facilities,
to ensure that information is appropriately verified and timeliness
standards are met.
4.1.1.1 Not less than 95% of the audited
files shall be in full compliance with all provider file requirements.
4.1.1.2 The audit shall be completed
no later than 90 calendar days prior to the SHCD.
4.1.2 The incoming contractor shall
notify and invite the Government to observe the contractor’s audit
no later than 30 calendar days prior to the scheduled audit. At
the time of the audit, the Government will identify the provider
and facility type of files to be audited.
4.1.3 The incoming
contractor shall submit a written Corrective Action Plan (CAP) to
the Government no later than five business days after the audit,
which addresses all credentialing and privileging files not in full compliance.
4.1.4 The incoming contractor shall
have corrected all deficient files to full compliance and inform
the Government no later than 30 calendar days after completion of
the audit. Documentation shall be completed in accordance with DD
Form 1423, CDRL, located in Section J of the applicable contract.
4.2 Provider Network PRV
4.2.1 The incoming contractor shall
validate they have established an adequate network in its geographical area
of responsibility for PCMs, BH providers, specialty care providers,
and inpatient health care facilities (institutional providers) no
later than 60 calendar days prior to the SHCD.
Note: For the purposes of assessing
adequacy, the validation shall assess all Prime Service Areas (PSAs)
in the geographical area of responsibility individually and not
the geographical area of responsibility as whole.
4.2.2 The incoming 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 (MM) systems, and supporting MM systems identified
by the Government not later than 60 calendar days prior to the SHCD.
• Loading PCMs into DEERS shall
begin no later than 150 calendar days prior to the SHCD.
• Fifty percent (50%) of the
PCMs shall be loaded into DEERS no later than 120 calendar days
prior to the SHCD.
• Seventy-five percent (75%)
of the PCMs shall be loaded into DEERS no later than 100 calendar
days prior to the SHCD.
• One hundred percent (100%)
of the PCMs shall be loaded into DEERS no later than 60 calendar
days prior to the SHCD.
Note: At a minimum, the contractor
shall load the required number of PCMs for every PSA.
4.2.3 The incoming contractor shall
validate accurate and complete provider system loads for all network providers.
4.2.3.1 The incoming contractor shall
submit load file completion report, in accordance with DD Form 1423, CDRL,
located in Section J of the applicable contract to the Government
which compare the percentage of providers loaded into the requisite
systems with the number of providers required by the contractor’s
NIP.
4.2.3.2 The reports shall include the
incoming contractor’s accuracy attestation to the Government regarding
the total number of provider system loads by category (PCMs, BH,
specialty care providers, and inpatient health care facilities)
and the percentage of records loaded that meet the scheduled accuracy
threshold listed below in all data fields.
4.2.3.3 The incoming contractor validation
standards are as follows:
• Fifty percent (50%) of all
providers loaded no later than 120 calendar days prior to the SHCD
at a 90% accuracy rate.
• Seventy-five percent (75%)
of all providers loaded no later than 90 calendar days prior to
the SHCD at a 90% accuracy rate.
• One hundred percent (100%)
of all providers loaded no later than 60 calendar days prior to
the SHCD at a 95% accuracy rate.
Note: At a minimum, the contractor
shall load the required number of providers for every PSA.
4.2.4 The incoming contractor shall
validate the completeness and accuracy of the online directory of network
providers.
4.2.4.1 The incoming contractor shall
submit validation reports to the Government as identified below.
The reports shall 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
NIP.
4.2.4.2 The incoming contractor validation
standards are as follows:
• Fifty percent (50%) of network
providers and health care facilities entered no later than 120 calendar
days prior to the SHCD at a 90% accuracy rate.
• Seventy-five percent (75%)
of network providers and health care facilities entered no later
than 90 calendar days prior to the SHCD at a 90% accuracy rate.
• One hundred percent (100%)
of network providers and health care facilities entered no later
than 60 calendar days prior SHCD at a 95% accuracy rate.
4.2.4.3 The incoming contractor shall
validate that its provider directory is online and operational 60 calendar
days prior to the SHCD at a 95% accuracy rate.
4.2.5 The incoming contractor shall
validate accurate and complete provider system loads for all specialty providers.
4.2.5.1 The incoming contractor shall
submit load file completion report, in accordance with DD Form 1423, CDRL,
located in Section J of the applicable contract to the Government
which compare the percentage of providers loaded into the requisite
systems with the number of providers required by the contractor’s
NIP.
4.2.5.2 The reports shall include the
incoming contractor’s accuracy attestation to the Government regarding
the total number of provider system loads by category (PCMs, BH,
specialty care providers, and inpatient health care facilities)
and the percentage of records loaded that meet the scheduled accuracy
threshold listed below in all data fields.
4.2.5.3 The incoming contractor validation
standards are as follows:
• Fifty percent (50%) of specialty
providers loaded no later than 120 calendar days prior to the SHCD
at a 90% accuracy rate.
• Seventy-five percent (75%)
of specialty providers loaded no later than 90 calendar days prior
to the SHCD at a 90% accuracy rate.
• One hundred percent (100%)
of specialty providers loaded no later than 60 calendar days prior
to the SHCD at a 95% accuracy rate.
Note: At a minimum, the contractor
shall load the required number of specialty providers for every
PSA.
4.2.6 The incoming
contractor shall validate accurate and complete provider system
loads for all BH providers.
4.2.6.1 The incoming contractor shall
submit load file completion report, in accordance with DD Form 1423, CDRL,
located in Section J of the applicable contract to the Government
which compare the percentage of providers loaded into the requisite
systems with the number of providers required by the contractor’s
NIP.
4.2.6.2 The reports shall include the
incoming contractor’s accuracy attestation to the Government regarding
the total number of provider system loads by category (PCMs, BH,
specialty care providers, and inpatient health care facilities)
and the percentage of records loaded that meet the scheduled accuracy
threshold listed below in all data fields.
4.2.6.3 The incoming contractor validation
standards are as follows:
• Seventy-five percent (75%)
of BH providers loaded no later than 120 calendar days prior to
the SHCD at a 90% accuracy rate.
• One hundred percent (100%)
of BH providers loaded no later than 90 calendar days prior to the
SHCD at a 95% accuracy rate.
Note: At a minimum, the contractor
shall load the required number of BH providers for every PSA.
4.2.7 The incoming contractor shall
validate accurate and complete provider system loads for all inpatient healthcare
facilities.
4.2.7.1 The incoming contractor shall
submit load file completion report, in accordance with DD Form 1423, CDRL,
located in Section J of the applicable contract to the Government
which compare the percentage of providers loaded into the requisite
systems with the number of providers required by the contractor’s
NIP.
4.2.7.2 The reports shall include the
incoming contractor’s accuracy attestation to the Government regarding
the total number of provider system loads by category (PCMs, BH,
specialty care providers, and inpatient health care facilities)
and the percentage of records loaded that meet the scheduled accuracy
threshold listed below in all data fields.
4.2.7.3 The incoming contractor validation
standards are as follows:
• Fifty percent (50%) of inpatient
healthcare facilities loaded no later than 120 calendar days prior
to the SHCD at a 90% accuracy rate.
• Seventy-five percent (75%)
of inpatient healthcare facilities loaded no later than 90 calendar
days prior to the SHCD at a 90% accuracy rate.
• One hundred percent (100%)
of inpatient healthcare facilities loaded no later than 60 calendar
days prior to the SHCD at a 95% accuracy rate.
Note: At a minimum, the contractor
shall load the required number of inpatient healthcare facilities
for every PSA.
4.2.8 The incoming
contractor shall provide the Government with a comprehensive briefing
on the processes, results, and course of actions no later than five
calendar days after completion of each PRV activity.
4.3 Provider Network PRAV
4.3.1 The incoming 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 to be deficient, the contractor shall submit
a detailed mitigation plan no later than 10 business days following
the Government’s findings.
4.3.2 Specific
PRAV activities, assessment techniques, and performance readiness
thresholds will be identified by the Government during the Transition
Specifications (TRANSPEC) Meeting.