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TRICARE Operations Manual 6010.62-M, April 2021
Transitions
Chapter 2
Section 4
Critical Processes (CPs) - Enrollment
Revision:  
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.
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