1.0 TRANSITION-IN GENERAL
1.1 The incoming contractor shall
develop an Enrollment Plan as identified in DD Form 1423, Contract
Data Requirements List (CDRL), located in Section J of the applicable
contract. Submission of the enrollment plan shall be no later than
180 calendar days prior to the start of health care delivery (SHCD).
1.2 The incoming contractor shall
resubmit a revised Enrollment Plan within 15 calendar days if the Enrollment
Plan is rejected by the Government.
1.3 The incoming
contractor shall have a fully operational enrollment system in accordance
with TRICARE Systems Manual (TSM) that supports all enrollment related
activities (i.e., Defense Enrollment Eligibility Reporting System
(DEERS) enrollment applications and Market/Military Medical Treatment
Facility (MTF) enrollment guidelines).
1.4 The incoming
contractor’s enrollment system shall be operational 90 calendar
days prior to the SHCD.
1.5 The incoming
contractor shall begin processing new enrollments at the start of
the open enrollment period in accordance with
Chapter
6.
2.0 TRANSFER OF ENROLLMENT FEES
2.1 DMDC will provide the incoming
contractor with an enrollment load file (Enrollment Gold File) between 60
to 75 calendar days prior to the SHCD.
2.2 The outgoing
contractor shall provide to the incoming contractor an enrollment
file that at a minimum includes frequency and payment methods of
enrollment fees and premiums no later than 180 calendar days prior to
the incoming contractor’s SHCD.
2.3 The outgoing
contractor shall provide to the incoming contractor the enrollment
information required for those Active Duty Family Members (ADFMs)
enrolled in TRICARE Prime residing outside of a Prime Service Area (PSA)
as described in
Chapter 6 no later
than 180 calendar days prior to the incoming contractor’s SHCD,
and monthly thereafter until the incoming contractor’s SHCD.
2.4 The outgoing contractor shall
provide to the incoming contractor a list of those beneficiaries
living greater than 100 miles from a Primary Care Manager (PCM)
and granted re-enrollment per National Defense Authorization Act
(NDAA) Fiscal Year (FY) 2016, Section 701 no later than 180 calendar
days prior the incoming contractor’s SHCD, and monthly thereafter
until the incoming contractor’s SHCD.
2.5 The outgoing
contractor shall provide to the incoming contractor a list of beneficiaries
with drive time waivers in place no later than 180 calendar days
prior the incoming contractor’s SHCD, and monthly thereafter until the
incoming contractor’s SHCD.
2.6 The incoming
contractor shall process the DMDC enrollment gold file no later
than five calendar days of receipt of the file.
2.7 The incoming contractor shall
reconcile the enrollment records received from the outgoing contractor
in accordance with TSM,
Chapter 3 of
all outstanding enrollment record discrepancies weekly after the
initial receipt.
2.8 The outgoing
contractor responsible for Continued Health Care Benefits Program
(CHCBP) shall provide to the incoming contractor enrollment and
billing information required for CHCBP enrollees no later than the
date specified at the Transition Specifications (TRANSPEC) Meeting.
See
Chapter 23, Section 3 for transition requirements
for the Catastrophic Cap and Deductible (CC&D) repository.
2.9 The Government will furnish
the outgoing contractor with a sample of the CHCBP Termination Notice format
no later than 120 calendar days prior to the SHCD.
3.0 ENROLLMENT ACTIONS DURING ENROLLMENT
DUAL PROCESSING
3.1 DMDC will create and deliver
the Enrollment Gold File to the incoming contractor (between 60
to 75 calendar days prior to the SHCD), at which time dual processing
begins.
3.2 The outgoing contractor shall
continue to process enrollments in accordance with
Chapter
6 until the incoming contractor’s SHCD.
3.3 The outgoing contractor shall
provide the incoming contractor with updated enrollment information
not less than weekly, starting with the dual processing, for enrollments
with an effective date prior to the SHCD (e.g., active duty enrollment,
mid-month enrollment, portability transfer).
3.4 The incoming contractor shall
effect an enrollment to begin on the SHCD once notified by the outgoing contractor
of the new enrollment (DMDC may run a report at the end of the transition
period that reflects new additions).
3.5 The outgoing
contractor shall send updated billing information to DEERS daily,
starting with the dual processing, until the incoming contractor’s
SHCD.
3.6 The incoming contractor shall
cancel the future enrollment segment and notify the outgoing contractor when
a current enrollment in the region requires deletion with an effective
date prior to the SHCD (e.g., transfers out, disenrollments for
failure to pay fees, cancellations).
3.7 The incoming
contractor shall cancel the future enrollment segment and notify
the outgoing contractor for all other enrollment actions with an
effective date prior to the SHCD (e.g., PCM changes, Defense Medical Information
System-Identification Code (DMIS-ID) changes, enrollment begin date
changes) when requested by the outgoing contractor.
3.8 The incoming contractor shall
verify and if necessary reinstate the future enrollment segment,
within three business days, when notified by the outgoing contractor
that their change has been effected.
3.9 The outgoing
and incoming contractor shall coordinate enrollment files to include
a list of fees collected and refunds issued, no less than weekly
to ensure that new enrollments and enrollment renewals are accurately and
timely reflected in the incoming contractor’s enrollment files and
in DEERS during the dual processing period.
4.0 ENROLLMENT FEES
4.1 The outgoing
contractor who collects the enrollment fees and premiums shall forward
the fees and/or premiums to the Government in accordance with
Chapter 6, Section 1.
4.2 The incoming contractor shall
obtain the cumulative total of enrollment fees and/or premiums and
paid-through dates for each policy from DEERS no later than 180
calendar days prior to the SHCD.
4.3 The Government
will provide dates to the incoming contractor to coordinate the
transition of allotment data with the Defense Finance and Accounting
Service (DFAS) and Uniformed Services pay centers at the TRANSPEC
Meeting.
4.4 The outgoing contractor shall
provide the incoming contractor health plan, demographic, and fees
and/or premiums information that are being paid monthly (i.e., by
allotment, recurring credit card, or Electronic Funds Transfer (EFT))
no later than 180 calendar days prior to the incoming contractor’s
SHCD.
4.4.1 The outgoing contractor shall
validate that the allotment file is accurate and correct BEFORE sending the
file to the incoming contractor if the outgoing contractor is using
a subcontractor or fiscal intermediary to process allotments.
4.4.2 The incoming contractor shall
reestablish monthly payment types in the least disruptive manner
for the beneficiary no later than 60 calendar days prior SHCD.
4.5 The incoming contractor shall
send enrollment renewal notices for all enrollees whose current enrollment
period expires on or after the SHCD no later than 45 calendar days
prior to the SHCD.
4.6 The incoming
contractor shall send billing statements where the enrollment fee
payment would be due on or after the SHCD no later than 45 calendar
days prior to the SHCD.
4.7 The outgoing
contractor shall transfer to the incoming contractor all outstanding
enrollment record discrepancies identified by DEERS Support Office
(DSO) and provide the list to the Government 60 calendar days prior
to the SHCD and at least weekly thereafter until all outstanding
records have been transferred.
4.8 The outgoing
contractor shall communicate, collaborate, and coordinate with the
incoming contractor to resolve any discrepancies of cumulative enrollment
fees and paid-through dates on policies inherited during the transition
90 calendar days prior to the SHCD and continuing for 90 calendar
days after the SHCD.
4.9 The incoming
contractor shall begin at the start of enrollment processing to
send fee information to DEERS using the Government furnished tools
as outlined in TSM,
Chapter 3.
5.0 PHASE-OUT OF ENROLLMENT ACTIVITIES
5.1 The outgoing contractor shall
amend renewal notices and billing statements (or include a stuffer
and/or insert) to advise the enrollee to direct any enrollment-related
correspondence and enrollment fee payments to the successor contractor
no later than 90 calendar days prior to the incoming contractor’s
SHCD.
5.2 The outgoing contractor shall
forward all enrollment-related correspondence and enrollment fee payments
to the incoming contractor within three business days of receipt.
This action shall begin at the incoming contractor’s SHCD.
5.3 The outgoing contractor shall
terminate enrollment marketing activities 60 calendar days prior
to the incoming contractor’s SHCD.
5.4 The outgoing
contractor shall transfer any enrollment requests or applications,
enrollment-related correspondence, or fee and/or premium payments
received after the open enrollment period with an effective date of
the incoming contractor’s SHCD to the incoming contractor by overnight
delivery at the outgoing contractor’s expense.
6.0 PERFORMANCE READINESS VALIDATION
(PRV)/PERFORMANCE READINESS ASSESSMENT AND VERIFICATION (PRAV)
During transition, the incoming
contractor’s performance readiness status regarding enrollment activities
will be subject to PRV/PRAV reviews as described below.
6.1 Enrollment
PRV
6.1.1 The incoming contractor shall
validate their enrollment system is operational and meets all contract requirements
(including, but not limited to, hardware and/or software operability;
compliance with system access requirements; interfaces with Government
systems; Market/MTF PCM assignment rule loading; and all billing, enrollment,
and collection transactions) no later than 120 calendar days prior
to the SHCD.
6.1.2 The incoming contractor shall
validate that it can perform enrollment transactions with at least
a 97% accuracy (to be considered accurate, all data elements within
an enrollment must be correct) for all TRICARE health plans and
CHCBP (where applicable) no later than 120 calendar days prior to
the SHCD.
6.1.3 The incoming contractor shall
validate its payment/billing system is operational, generate bills,
and post payments to the appropriate systems no later than 120 calendar
days prior to the SHCD.
6.1.4 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 the completion of each PRV activity.
6.2 Enrollment
PRAV
6.2.1 The incoming contractor shall
comply with the Government’s approach for assessment and verification of
the contractor’s performance readiness regarding enrollment activities
as described above.
6.2.2 The incoming
contractor shall submit a detailed mitigation plan no later than
10 business days following the Government’s findings if, after review,
the Government finds the contractor’s performance readiness for
enrollment processing to be deficient.
6.2.3 Specific
PRAV activities, assessment techniques, and performance readiness
thresholds will be identified by the Government during the TRANSPEC
Meeting.