1.0 CYBERSECURITY REQUIREMENTS
The incoming contractor shall
complete and submit all required forms (e.g., System Security Plan
(SSP)) in accordance with the TRICARE Systems Manual (TSM),
Chapter
12.0 PERSONNEL SECURITY AND USER
ACCESS REQUIREMENTS
2.1 The incoming contractor’s Facility
Security Officer (FSO) shall attend a meeting with the Defense Health Agency
(DHA) Personnel Security Branch (PSB) within 30 calendar days after
contract award to review Personnel Security requirements and procedures
for requesting background checks and Common Access Cards (CACs)
in accordance with the TSM,
Chapter 1, Section 1.1.
2.2 The incoming contractor shall
ensure personnel complete appropriate background and security checks in
accordance with TSM,
Chapter 1, Section 1.1.
2.3 The incoming
contractor shall obtain CACs from Real-Time Automated Personnel
Identification System (RAPIDS) sites.
2.3.1 The incoming
contractor shall build in the distance and appointment capacity
for obtaining CACs in accordance with
Chapter
2 transition requirements.
3.0 CONNECTIVITY REQUIREMENTS
The incoming contractor shall
complete and submit the required forms (e.g., Business to Business
(B2B) Questionnaire, DD Form 2875, etc.) in accordance with TSM,
Chapter
1.
4.0 SYSTEM INTERFACE MEETINGS
4.1 The incoming contractor shall
provide to the Government Designated Authority (GDA) the name, address,
and telephone number of the technical Points of Contact (POCs) at
the Transition Specifications (TRANSPEC) Meeting, and shall ensure
participation by subject matter experts in all scheduled meetings
for the understanding and clarification of systems implementation
requirements at the Interface Meetings listed below.
4.2 The incoming contractor shall
communicate, collaborate, and coordinate with the GDA no later than
30 calendar days from contract award to schedule the following interface
meetings:
• System Integration Interface
Meeting (SIIM) to identify all Defense Enrollment Eligibility Reporting
System (DEERS) systems interfaces and applications necessary to
meet the requirements of this contract and TSM,
Chapter
3.
• TRICARE Encounter Data (TED)
Integration Interface Meeting (TIIM) to identify all TED systems
interfaces and applications necessary to meet the requirements of
this contract and TSM,
Chapter 2.
• Military Health System (MHS)
Genesis Interface Meeting to identify all MHS Genesis systems interfaces
and applications necessary to meet the requirements of this contract,
Chapter
7, and TSM,
Chapter 1.
• Referral Management System
Interface Meeting to identify all referral systems interfaces and
applications necessary to meet the requirements of this contract,
Chapter
7, and TSM,
Chapter 1.
• Uniformed Services Pay Centers
Interface Meeting to identify all pay center systems interfaces
and applications necessary to meet the requirements of this contract
and TSM,
Chapter 1.
• E-Commerce System Interface
Meeting to identify all contract deliverable systems interfaces
and applications necessary to meet the requirements of this contract
and
Chapter 7.
• DHA-Great Lakes (DHA-GL) [the
Specified Authorization Staff (SAS) for Army, Air Force, Navy, Marine
Corps, Coast Guard, and National Guard TRICARE Prime Remote (TPR)
enrollees] Interconnectivity meeting to identify all contract deliverable,
systems interfaces, and applications necessary to meet the requirements
of this contract,
Chapters 16,
17,
and TSM,
Chapter 1.
4.3 The Government will collaborate
with the incoming contractor as to the exact date, length, and location of
all interface meeting(s), and will provide the meeting agenda prior
to the meeting(s).
5.0 UNIFORMED SERVICES PAY CENTER
TRANSITIONS
5.1 The GDA will coordinate and
schedule with the incoming and outgoing contractors the transition
of beneficiary allotment payments from the outgoing to the incoming
contractor.
5.2 The outgoing contractor shall
stop all allotments by sending a “stop allotment notice” to the
Uniformed Services pay center(s) after the last payment under their
contract has been received. To stop allotments, the notice has to
be at the Uniformed Services pay center(s) by the sixth calendar
day of the preceding month. For example, to stop for May 1st, the
“stop allotment notice” has to be at the Uniformed Services pay
center(s) by April 6th.
5.3 The outgoing
contractor shall communicate, collaborate, and coordinate the schedule
with the GDA no later than 90 calendar days following contract award.
5.4 The incoming contractor shall
send an “allotment request” to the Uniformed Services pay center(s)
no later than the sixth calendar day of the month prior to the first
payment being due. For example, to start May 1st, the “start request”
must be at the Uniformed Services pay center(s) by April 6th.
6.0 SYSTEMS DEVELOPEMENT
The GDA, no later than 60 calendar
days prior to the start of health care delivery (SHCD), will test
the non-claims processing systems and the telecommunications interconnections
capabilities, to determine whether the systems meet the requirements
of the Government and the contract.
6.1 The incoming
contractor shall include a demonstration to the Government of its
non-claims processing system(s), and the telecommunications interconnections
capabilities.
6.2 The incoming contractor shall
effect any modifications required by DHA no later than 30 calendar
days prior to the SHCD.
7.0 CLAIMS PROCESSING SYSTEM AND
OPERATIONS
7.1 The incoming contractor shall
perform initial conversion and testing of all Automated Data Processing (ADP)
files (e.g., provider files, claims history files, and beneficiary
history) no later than 30 calendar days following receipt of the
files from the outgoing contractor.
7.1.1 The incoming
contractor shall conduct integration testing to validate implementation
process, internal interfaces to each of the Government’s systems,
integration, and functionality no later than 60 calendar days prior to
the SHCD.
7.1.2 The incoming contractor shall
identify a primary and secondary Testing Coordinator that is responsible for
testing preparations, coordination of tests, identification of issues
and resolution, verification of test results, and shall communicate,
collaborate, and coordinate integration testing with the Government
Test Managers.
7.2 The Government
will instruct the incoming contractor on how issues will be reported
and tracked during integration testing at the interface meeting.
7.3 The Government will coordinate
with the incoming contractor throughout transition to plan, execute, and
evaluate the integration testing efforts.
8.0 TRANSACTION TESTING
8.1 The incoming contractor shall,
follow Health Insurance Portability and Accountability Act (HIPAA)
and Contracting Officer (CO) written direction in regards to transaction
testing. At a minimum, testing shall include the following:
• The incoming contractor shall
conduct initial testing and compliance with all HIPAA mandated Transactions, Code
Sets, and Identifiers (TCS&I) adopted by HIPAA Final Rule in
the Federal Register prior to the SHCD, except for
those TCS&I specifically stated by the DHA as not apply to use
by the DHA.
• The incoming contractor shall
test their capability to create, send, and receive compliant transactions
and shall provide written evidence (e.g., certification from a transaction
testing service) of successful testing of their capabilities to
create, send, and receive compliant transactions to the contracting
offices no later than 60 calendar days prior to the SHCD.
• The incoming contract shall
test its capability no later than 60 calendar days prior to the
SHCD to comply with any TCS&I Final Rule(s) adopted in the Federal
Register prior to the SHCD but with required compliance date after
the SHCD.
• The incoming contractor shall
provide written evidence (e.g., certification from a transaction
testing service) of successful testing of their compliance with
the requirements of the adopted Final Rule(s) to the contracting offices
no later than 60 calendar days prior to the applicable mandated
implementation date(s) of the Final Rule(s).
8.2 The incoming contractor shall
make necessary corrections and re-test until a successful outcome
is achieved in the event transaction compliance failures occur during
testing. Failure to certify HIPAA TCS&I compliance with HIPAA
named and adopted TCS&I no later than 60 calendar days prior
to the SHCD may result in delay of the SHCD.
8.3 The incoming contractor shall
test their capability to process standard transactions. This testing
shall be “cradle-to-grave” testing from receipt of the transactions,
through processing, and completion of all associated functions including
creating and transmitting associated response transactions. Testing
involving the receipt and processing of claims transactions shall
also include the submission to and acceptance by the DHA of TED
records and the creation of contract compliant electronic Explanation
Of Benefits (EOB). The incoming contractor shall complete “cradle-to-grave”
testing no later than 30 calendar days prior to the SHCD.
Note: The TRICARE Health Plan (THP)
(including business associate contractors) may be selected for a
no-notice HIPAA transactions compliance audit at any time, initiated
by the Centers for Medicare and Medicaid Services (CMS) through
the HIPAA Compliance Review Program.
9.0 TED RECORDS
9.1 The incoming
contractor shall ensure the TED record complies with the TSM,
Chapter
2 and the contract no later than 30 calendar days prior
to the SHCD.
9.2 The incoming contractor shall
ensure the TRICARE Encounter Provider (TEPRV) record complies with
the TSM,
Chapter 2 and
the contract no later than 30 calendar days prior to the SHCD.
9.3 The incoming contractor must
demonstrate the ability to successfully create and submit all TED
record types and TEPRVs no later than 30 calendar days prior to
the SHCD. This includes, but is not limited to, adjustment, denial
and cancellation records.
10.0 DUPLICATE CLAIMS SYSTEM (DCS)
10.1 Incoming Contractor Requirements
10.1.1 The incoming contractor shall
utilize DCS for the identification of post-payment potential duplicate claims
payments via the Patient Encounter Processing and Reporting (PEPR)
Portal in accordance with the TSM,
Chapter
4.
10.1.2 The incoming contractor shall
participate in Government furnished DCS training.
10.1.3 The incoming contractor shall
complete all user access requirements in accordance with the TSM,
Chapter
1 prior to the initiation of training.
10.1.4 The Government will coordinate
with the incoming contractor for the scheduling of DCS training
no later than 60 calendar days following the SHCD.
10.1.5 The Government will establish
a date when the incoming contractor will assume full responsibility
for resolving all existing potential duplicate claim sets from the
outgoing contractor.
10.1.6 The incoming contractor shall
begin using DCS to resolve identified potential duplicate claim
sets “owned” by the outgoing contractor and pursue any existing
recoupments received from the outgoing contractor upon reassignment
by the Government to the incoming contractor.
10.1.6.1 The incoming contractor shall
apply the adjustment to the set without modifying the recoupment amount
if the recoupment amount was zero when the set was transferred from
the outgoing contractor.
10.1.6.2 The incoming contractor shall
apply the adjustment to the set while leaving the actual recoupment amount
as zero dollars. Resolution will result in a Validate status,
requiring an explanation by the incoming contractor that the outgoing
contractor did not enter the actual recoupment amount.
10.1.7 The incoming contractor shall
identify at least one individual and one alternate (who are, or
will be, trained in the use of the DCS, and who are able to perform
the required research and determine whether a particular claim is
within their processing jurisdiction), to serve as the DCS POCs
for assigned DCS claim sets.
10.1.8 The incoming contractor shall
provide the name(s), title(s), business address(es), and business telephone
number(s) of their DCS POCs to the Government no later than 10 business
days prior to implementation of DCS to production.
10.1.9 The Government will provide
each contractor with the list of all DCS POCs. Whenever a new contract
is awarded, the Government will notify all contractors of the new
contractor’s DCS POC.
10.1.10 The incoming contractor shall
maintain and provide updated POC information to the Government no later
than 14 calendar days following any change.
10.2 Outgoing Contractor Requirements
10.2.1 The outgoing contractor shall
package and forward refund checks received and offsets taken for recoupments
associated with duplicate claims payments to the incoming contractor
and provide recoupment files associated with in progress duplicate
claim recoupment within 120 calendar days following SHCD.
10.2.2 The outgoing contractor shall
cease researching Open claim sets and initiating
new recoupments associated with duplicate claim payments upon reassignment
to the incoming contractor.
10.2.3 The outgoing contractor shall
cease entering refund data and linking adjustment data in the DCS
for Pending and Validate claim
sets upon reassignment to the incoming contractor.
10.2.4 The outgoing contractor shall
move all Open DCS claim sets to a Pending, Validate,
or Closed status by the last day of TED submissions
in accordance with the contractor’s transition-out plan.
10.2.5 The outgoing contractor shall
stop entering refund and adjustment data on the DCS upon reassignment
to the incoming contractor. Refunds may be received and TED adjustments
may still be submitted for claims in Open and Pending sets.
In this case, the incoming contractor may be required to resolve
the set without knowing the amount of the refund received by the
outgoing contractor.
10.2.6 The outgoing contractor shall
phase-out the use of the automated TRICARE DCS in accordance with TSM,
Chapter
4, Integrated Master Plan (IMP), and Integrated Master
Schedule (IMS) as identified by DD Form 1423, Contract Data Requirements
List (CDRL), located in Section J of the applicable contract.
11.0 PERFORMANCE ASSESSMENT REPORTING
11.1 Training
The incoming contractor shall
schedule initial training on the submission of deliverables within
30 calendar days after award. Additional training for new users
will be provided throughout the contract upon request.
11.2 Technical Support
Technical support is provided
during the business week. A POC for access and deliverable submission
will be provided during initial training.
12.0 INTERCONNECTIVITY BETWEEN THE
CONTRACTOR AND DHA-GL (THE SAS FOR ARMY, AIR FORCE, NAVY, MARINE
CORPS, COAST GUARD, AND NATIONAL GUARD TPR ENROLLEES)
12.1 The incoming contractor shall
provide access for entry and edit of referrals into existing systems supporting
this contract.
12.2 The incoming
contractor shall propose one of the following access options:
12.2.1 Government staff physically
located in Great Lakes, IL, accessing the contractor’s system;
12.2.2 Contractor staff physically
located in Great Lakes, IL, accessing the contractor’s system; or
12.2.3 Government personnel performing
a backup role in the event contractor personnel are unavailable due
to annual or sick leave or another reason.
12.3 The contractor shall ensure
the contractor’s system can be accessed over a secure connection
by Government employees who are teleworking using a Government furnished
laptop.
12.4 The incoming contractor shall
create a standard management listing for all pending referrals requiring SAS
review. The listing will be made available on-line to the SAS.
12.5 The incoming contractor shall
propose the design for the listing to the SAS for approval 30 calendar
days prior to the SHCD.
13.0 DMDC
TEST ENVIRONMENT
13.1 The incoming contractor shall
assume that an exclusive testing environment will not be available
for development/testing of their internal processes and applications.
All testing will occur in the DMDC customer test environment, which
is shared by all DMDC customers, including other DHA contractors.
13.2 The incoming
contractor shall attend training provided by DMDC on DMDC maintained
applications used by the incoming contractor.
13.3 The incoming
contractor shall provide a list of attendees no later than 10 business
days prior to DMDC training.