5.0 DHA PERFORMANCE READINESS VALIDATION
(PRV)/PERFORMANCE READINESS ASSESSMENT AND VERIFICATION (PRAV)
During transition, the incoming
contractor’s performance readiness status regarding claims processing
will be subject to PRV/PRAV reviews as described below.
5.1 Claims
Processing PRV
5.1.1 The incoming contractor shall
validate its ability to process all TRICARE claim types with a minimum
of a 98% accuracy rate no later than 90 calendar days prior to the
SHCD. Claims testing shall include multiple claim types that represent
a level of complexity involved in claims for TRICARE benefits. Validation
shall include claims processing at the operational volume, stress
testing at projected claims volumes and include claims representing all
active demonstrations.
5.1.2 The contractor
shall provide validation results, to include test scenarios used,
to the Government within 10 business days following conclusion of
the contractor’s validation.
5.1.3 The incoming
contractor shall validate it can receive and utilize claims history
file transfers from the outgoing contractor no later than 14 calendar
days following receipt of the files from the outgoing contractor.
5.1.3.1 The incoming contractor shall
include in its validation process a test of a statistically valid
number of records to ensure readability and usability of information.
Tests shall include accessibility to records, accuracy of data,
and the contractor’s ability to use the data to correctly apply
TRICARE policy, such as time or episode limited benefits.
5.1.3.2 Results must reach a minimum
of 98% accuracy no later than 45 calendar days prior to the SHCD.
5.1.3.3 The incoming contractor shall
provide test scenarios as well as testing results to the Government
no later than 45 calendar days prior to the SHCD.
5.1.4 The incoming contractor shall
develop tests to ensure reimbursement rate system applications are correctly
loaded and functioning properly. Areas tested shall include negotiated
network discount rates, non-network rates, and specific reimbursement
rates as required by policy (e.g., Sole Community Hospitals (SCHs),
low/high-volume mental health facilities, partial hospitalization
facilities). Validation shall include demonstrating a variety of
claims scenarios where reimbursement rate system applications are
applied.
5.1.4.1 The incoming contractor shall
complete its reimbursement rate system validation no later than
90 calendar days prior to the SHCD and provide the Government with
validation results, to include test case scenarios used, within
10 business days following conclusion of the contractor’s validation.
5.1.4.2 The incoming contractor shall
submit a detailed mitigation plan no later than 14 calendar days following
receipt of the Government’s findings, if, after review, the Government
finds the contractor’s testing or outcomes are deficient.
5.1.4.3 The incoming contractor shall
process test claims no later than 120 calendar days prior to the
SHCD with a first pass auto-adjudication rate of 80% of the test
claims volume that do not require human intervention (i.e. preauthorization
or other manual reviews).
5.1.5 The incoming
contractor shall validate that its claims processing system clearly
identifies and appropriately differentiates between beneficiary
categories to facilitate claims processing accuracy by testing a multitude
of scenarios with different beneficiary categories (as specified
in the TRICARE Systems Manual (TSM)) to ensure appropriate application
of cost-shares, co-pays and rates.
5.1.5.1 The incoming contractor shall
complete its system testing no later than 120 calendar days prior
to the SHCD with a 95% accuracy rate. The contractor shall complete
its claims processing system differentiation validation no later
than 120 calendar days prior to the SHCD and provide the Government
with validation results, to include test case scenarios used, within
10 business days following conclusion of the contractor’s validation.
5.1.5.2 The incoming contractor shall
submit a detailed mitigation plan no later than 10 business days,
if after review, the Government finds the contractor’s testing or
outcomes to be deficient.
5.1.6 The incoming
contractor shall validate that the contractor’s claims processing
system accurately and appropriately applies referrals and authorizations.
5.1.7 The incoming contractor shall
validate its bi-directional referral, authorization and claims interface system
with DHA-Great Lakes (DHA-GL) is operational no later than 60 calendar
days prior to the SHCD.
5.2 Claims
Processing PRAV
5.2.1 The incoming contractor shall
comply with the Government’s approach for assessment and verification of
the contractor’s performance readiness regarding claims activities
as described above.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 incoming contractor’s
performance readiness for claims processing to be deficient.Specific
PRAV activities, assessment techniques, and performance readiness
thresholds will be identified by the Government during the Transition
Specification (TRANSPEC) Meeting.