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TRICARE Operations Manual 6010.62-M, April 2021
Transitions
Chapter 2
Section 2
Systems Development
Revision:  
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 1
2.0  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.
2.3.2  The incoming contractor shall use the RAPIDS locator website (https://idco.dmdc.osd.mil/idco/) for scheduling personnel who require CACs.
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.
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