2.0 PERFORMANCE READINESS VALIDATION
(PRV)/PERFORMANCE READINESS ASSESSMENT AND VERIFICATION (PRAV)
During transition, the incoming
contractor’s performance readiness status regarding RM will be subject
to PRV/PRAV reviews as described below.
2.1 RM
PRV
2.1.1 The incoming contractor shall
validate its RM system can interface with the Government’s RM systems (MHS
Genesis and RM Suite (375)).
2.1.2 The incoming
contractor shall validate its interface meets two criteria:
2.1.2.1 Markets/MTFs can send and receive
referrals with priority to those with a high KSA value with no technical
problems, and
2.1.2.2 The contractor sends referrals
and authorizations in accordance with the Market/MTF Capability Table
with 95% accuracy, as listed in
paragraph 2.1.9.2.
2.1.3 The incoming contractor shall
validate its RM systems can effectively interface with the Government’s RM
system(s), Defense Enrollment Eligibility Reporting System (DEERS),
contractor’s claims systems, network provider directory, and the
system network providers utilize to submit referrals and authorization
no later than 60 calendar days prior to the SHCD.
2.1.4 The incoming contractor shall
test, validate, and produce connectivity test results on all interfaces.
2.1.5 The incoming contractor shall
validate all aspects of its referral, authorization and command
approval (overseas only) processes by utilizing test scenarios which
include referrals to Market/MTF and network providers and referrals
from contractor to Market/MTF no later than 60 calendar days prior
to the SHCD.
2.1.6 The incoming contractor’s process
validation shall encompass all beneficiary categories and will use live
data from the Government’s RM system as part of the validation.
2.1.7 The incoming contractor shall
validate that its system can timely and accurately communicate referral, authorization
determinations with beneficiaries, network providers, Government
systems and claims systems without technical problems.
2.1.8 The incoming contractor shall
validate its ability to communicate with beneficiaries with multiple referral
status alerts and notification options, including email, text, web-portal
and hardcopy letters, to include beneficiary view and print capabilities.
2.1.9 The incoming contractor’s validation
shall demonstrate their RM system’s ability to accurately process 90%
of all requests within one business day and 100% within two business
days.
2.1.9.1 The contractor shall validate
its RM system (e.g., approval/denial letters) is accessible by the Government,
beneficiaries, and providers.
2.1.9.2 The incoming contractor shall
validate that referrals processed meet contract requirements with
a 95% accuracy rate. To be considered accurate, processed referral
shall include:
• Correct beneficiary
• Correct beneficiary demographics
• To include sponsor’s last four
digits of the Social Security Number (SSN) or Department of Defense
(DoD) ID Number
• Date of Birth (DOB)
• Unique Identifier Number (UIN)
is present if Market/MTF generated request
• Correct Servicing Provider
• Correct Servicing Specialty
• Correct Episode of Care (EOC)
• Evaluate and Treat
• Evaluate only
• Number of visits
• Length of authorization
• Range of Current Procedural
Terminology (CPT) codes
2.2 RM PRAV
2.2.1 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.
2.2.2 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. Specific PRAV activities,
assessment techniques, and performance readiness thresholds will
be identified by the Government during the Transition Specifications
(TRANSPEC) Meeting.