2.0 CONTRACT ADMINISTRATION AND
INSTRUCTIONS TO CONTRACTOR
2.1 The provisions
of
Chapter 1, Section 2 are applicable to the
TOP. Additionally, the TOP contractor shall coordinate with the
Defense Health Agency (DHA) Contracting Officer (CO), the appropriate
DHA Contracting Officer Representative (COR), and the TRICARE Overseas
Program Office (TOPO) on any TOP policy or contractual issue that
requires additional Government clarification or assistance to resolve.
2.2 The
provisions of
Chapter 1, Section 2, paragraph 4.0 are superseded
as described in
paragraphs 2.2.1 through
2.2.6.
2.2.1 A
14 calendar day notice will be provided by the DHA Procurement Contracting
Officer (PCO) for all meetings hosted by DHA.
2.2.2 The TOP contractor shall provide
up to four contractor representatives at the Performance Readiness
Validation briefing at DHA.
2.2.3 The
TOP contractor shall provide at least two contractor representatives
for transition briefings/meetings with each overseas Military Treatment
Facility (MTF) and TAO. All briefings/meetings must be completed
no later than 60 calendar days prior to the start of health care
delivery (SHCD). These briefings/meetings shall be targeted towards
command suite/key leaders and their staff and shall encompass all
key contract areas where collaboration between the contractor and
the MTF/TRICARE Area Office (TAO) will occur.
2.2.4 The TOP contractor shall provide
annual representation at two contractor conferences (senior management
level) at DHA. The contractor shall also provide up to four contractor representatives
at up to four additional meetings at the direction of the CO per
contract year.
2.2.5 The TOP
contractor shall provide representation at semiannual TOP operational
meetings to be held at DHA Aurora with TOPO, TAO, and service representation.
2.2.6 The
TOP contractor shall provide two contractor representatives at up
to 18 additional meetings/site visits at the direction of the CO
per option period.
8.0 TRANSITION-IN REQUIREMENTS
8.1 Systems Development
Approximately 80 calendar days
prior to the initiation of health care delivery, the non-claims processing
systems and the telecommunications interconnections between these
systems shall be reviewed by the DHA or its designees, to include
a demonstration by the contractor of the system(s) capabilities,
to determine whether the systems satisfy the requirements of TRICARE
as otherwise provided in the contract. This includes the telecommunications
links with DHA and Defense Enrollment Eligibility Reporting System
(DEERS) and the Business-to-Business Gateway (B2B). The review will
also confirm that the hardware, software, and communications links
required for operating the automated TRICARE Duplicate Claims System
(DCS) have been installed and are ready for DHA installation of
the DCS application software (see the TRICARE Systems Manual (TSM),
Chapter
4). The contractor shall implement any modifications required
by DHA prior to the initiation of services.
8.2 Execution
of Agreements with Contract Providers
8.2.1 All contract
provider agreements shall be executed, and loaded to the contractor’s
system, 80 calendar days prior to the start of health care delivery,
or at such other time as is mutually agreed between the contractor
and DHA.
8.2.2 The contractor
shall report on network adequacy on a monthly basis during the transition.
8.3 See
Section 15, for instructions
regarding Statements of Responsibilities (SORs). In addition to the
SOR requirements in these referenced paragraphs, the TOP contractor
shall also execute a SOR with each TAO Director no later than 60
calendar days prior to the SHCD.
8.4 Enrollment Transition
The contractor shall begin
the enrollment process no later than (NLT) 60 calendar days prior
to the scheduled SHCD, with actual enrollment processing to begin
40 days prior to the SHCD, subject to DHA approval of systems under
the contract.
8.4.1 For enrollments
in the region with an effective date prior to the SCHD (e.g., active
duty (AD) enrollment, mid-month enrollment; transfer-in), the incoming
contractor must effect an enrollment to begin on the SHCD once notified
by the outgoing contractor of the new enrollment. (Defense Manpower
Data Center (DMDC) may run a report at the end of the transition
period that reflects new additions.)
8.4.2 When the outgoing contractor
requests deletion of current enrollments with an effective date
prior to the SHCD (e.g., transfers out; disenrollments for failure
to pay fees; cancellations, etc.), the incoming contractor must
cancel the future enrollment segment and notify the outgoing contractor when
this action has been completed.
8.4.3 For all other enrollment actions
with an effective date prior to SHCD (e.g., Primary Care Manager
(PCM) changes; Defense Medical Information System-Identification
Code (DMIS-ID) changes; enrollment begin date changes; etc.), requested
by the outgoing contractor, the incoming contractor must cancel
the future enrollment segment and notify the outgoing contractor
when this action has been completed. When notified by the outgoing
contractor that their change has been effected, the incoming contractor
must reinstate the future enrollment segment.
8.4.4 Once health care delivery begins,
all enrollment actions will be accomplished by the incoming contractor.
If the outgoing contractor requires a retroactive change, they must
submit their request to the incoming contractor who will perform
the change and notify the outgoing contractor when it is complete.
8.5 Transfer of Enrollment Files
8.5.1 The incoming contractor shall
obtain enrollment information from DEERS through an initial enrollment
load file. DMDC will provide the incoming contractor with an incremental
enrollment load file for each contract transition. The incoming
contractor shall process each enrollment load file within 24 hours
or less from receipt of the file.
Note: Each contract transition shall
require a three-day freeze of enrollment and claim processing. This
freeze will occur beginning the first weekend that precedes the
60 day window prior to the SHCD. The actual calendar dates will
be determined during the transition meeting.
8.5.2 The incoming contractor shall
send enrollment renewal notices for all enrollees whose current
enrollment period expires on or after the SHCD. The incoming contractor
shall send billing statements where the enrollment fee payment would
be due on or after the SHCD. The incoming contractor shall start
sending billing notices and process renewals 45 days prior to the
SHCD.
8.5.3 Outstanding
enrollment record discrepancies and issues reported to the DEERS
Support Office (DSO) by the outgoing contractor will be transferred
to the incoming contractor for reconciliation. Records will be reconciled
in accordance with TSM,
Chapter 3.
8.6 TRICARE Service Center (TSC)
Phase-In
8.6.1 The incoming
contractor shall utilize the existing TSCs. The outgoing contractor
shall allow reasonable access to the incoming contractor throughout
the transition period to become familiar with the communication
lines, equipment and office layout.
8.6.2 The final schedule for access
to and occupancy of the TSCs will be determined at the Transition
Specifications Meeting. The approved schedule must allow the outgoing
contractor to fulfill all contract requirements through the last
day of health care delivery, and must provide the incoming contractor
sufficient access to the TSC to prepare for delivery of all required
functions on the first day of their contract.
8.6.3 All Contractor Customer Service,
Education and Health Care Finder (HCF) Field Representatives and
overseas TSC representatives shall be fully trained and available
for all duties no less than 80 calendar days prior to initiation
of health care services.
Note: Overseas TSCs are managed by
the MTFs and are jointly staffed by MTF and TOP contractor personnel.
The TOP contractor is responsible for providing on-site Beneficiary
Service Representative (BSR) support in all TSC locations.
8.7 Contractor File Conversions
and Testing
8.7.1 The incoming
contractor shall perform initial conversion and testing of all Automated
Data Processing (ADP) files (e.g., provider files, pricing files,
and beneficiary history) NLT 30 calendar days following receipt
of the files from the outgoing contractor(s).
8.7.2 Integration testing will be
conducted to validate the contractor’s internal interfaces to each of
the TRICARE Military Health Systems (MHSs). This testing will verify
the contractor’s system integration, functionality, and implementation
process. The incoming contractor shall be responsible for the preparation
and completion of Integration Testing 45 days prior to the SHCD.
(See the TSM,
Chapter 1, Section 1.1, paragraph 2.0.)
8.7.3 Contractors shall provide certification
of compliance with the National Institute of Standards and Technology
(NIST)-based Information Assurance (IA) program identified in the
TSM,
Chapter 1, Section 1.1, to fulfill all system
access requirements prior to connecting with the MHS and/or the
initiation of Integration Testing.
8.7.4 DHA Test Managers will work
with the contractor to plan, execute and evaluate the Integration
Testing efforts. The contractor shall identify a primary and a back-up
Testing Coordinator to work with the DHA Test Managers. The Testing
Coordinator is responsible for contractor testing preparations,
coordination of tests, identification of issues and their resolution,
and verification of test results. A web application will be available
for use by contractor Test Coordinators to report and track issues
and problems identified during integration testing.
8.8 Receipt of Outgoing Contractor’s
Weekly Shipment of History Updates and Dual Operations
8.8.1 Beginning with the 120th calendar
day prior to the SHCD and continuing for 180 calendar days after
the SHCD, the incoming contractor shall convert the weekly shipments
of the beneficiary history updates from the outgoing contractor(s)
within two working days following receipt. These files shall be
validated by the incoming contractor before use. Tests for claims
and duplicate claims shall be performed within two workdays following
conversion. Following the SHCD, these files shall be loaded to history
and used for claims processing.
8.8.2 During the 180 calendar days
after the SHCD when both the incoming and outgoing contractors are
processing claims, both contractors shall maintain close interface
on history update exchanges and provider file information. During
the first 60 calendar days of dual operations, the contractors shall
exchange beneficiary history updates with each contractor’s claims
processing cycle run. Thereafter, the exchange shall not be less
than twice per week until the end of dual processing. The incoming
contractor shall assume total responsibility for the maintenance
of the TRICARE Encounter Provider Record (TEPRV) beginning with
the SHCD. The incoming contractor will coordinate and cooperate
with the outgoing contractor to ensure that the outgoing contractor
can continue to process claims accurately; conversely, the outgoing
contractor has responsibility to notify the incoming contractor
of any changes in provider status that they become aware of through
their operations.
8.9 Transition-In
Requirements Related To Transitional Cases
8.9.1 In notifying beneficiaries
of the transition to another contractor, both the incoming and outgoing
contractors shall include instructions on how the beneficiary may
obtain assistance with transitional care. If the outgoing contractor
succeeds itself, costs related to each contract will be kept separate
for purposes of contract accountability.
8.9.2 Non-Network
Inpatient Transitional Cases
These are beneficiaries who
are inpatients (occupying an inpatient bed) at 0001 hours on the
first day of any health care contract period in which the incoming
contractor begins health care delivery. In the case of Diagnosis
Related Group (DRG) reimbursement, the outgoing contractor shall
pay through the first month of health care delivery or the date
of discharge, whichever occurs first. If the facility is reimbursed
on a per diem basis, the outgoing contractor is responsible for
payment of all the institutional charges accrued prior to 0001 hours
on the first day of health care delivery, under the incoming contractor.
The incoming contractor thereafter is responsible for payment.
8.9.3 Non-Network Outpatient/Professional
Transitional Cases
These
are cases, such as obstetric care, that are billed and payable under
“Global” billing provisions of Current Procedural Terminology, 4th
edition (CPT-4), HCFA Common Procedure Coding System (HCPCS), or
local coding in use at the time of contract transition, and where
an Episode Of Care (EOC) shall have commenced during the period
of health care delivery of the outgoing contractor and continues,
uninterrupted, after the SHCD by the incoming contractor. Outpatient/professional
services related to transitional cases are the responsibility of
the outgoing contractor for services delivered prior to 0001 hours
on the first day of health care delivery and of the incoming contractor
thereafter.
8.9.4 Network
Inpatient Care During Contract Transition
The status of network provider
changes (provider’s network agreement with the outgoing contractor
is terminated resulting in the provider’s loss of network status)
with the SHCD of the new contract. As a result, claims for inpatient
care shall be reimbursed in accordance with
paragraph 8.9.2 for non-network transitional
cases. Beneficiary copay is based on the date of admission; therefore,
Prime beneficiaries who are inpatients as described in
paragraph 8.9.2,
shall continue to be subject to Prime network copayments and shall
not be subject to Point Of Service (POS) copayments.
8.9.5 Home Health Care (HHC) During
Contract Transition
HHC, for
a 60-day EOC, initiated during the outgoing contractor’s health
care delivery period and extending, uninterrupted, into the health
care delivery period of the incoming contractor are considered to
be transitional cases. Reimbursement for both the Request for Anticipated
Payment (RAP) and the final claim shall be the responsibility of
the outgoing contractor for the entire 60-day episodes covering
the transition period from the outgoing to the incoming contractor.
8.10 Prior Authorizations and Referrals
The incoming contractor shall
honor outstanding prior authorizations and referrals issued by the outgoing
contractor, covering care through 60 days after the SHCD under the
incoming contract, in accordance with the outgoing contractors existing
practices and protocols, within the scope of the TRICARE program
and applicable regulations or statutes. In the case of Residential
Treatment Care (RTC) care, both the incoming and outgoing contractors
are responsible for authorizing that part of the stay falling within
their areas of responsibility; however, the incoming contractor
may utilize the authorization issued by the outgoing contractor
as the basis for continued stay. This transition period for prior
authorizations and referrals is extended to one year for obstetrical
care or any other condition for which a one-year authorization has
been issued.
8.11 Case
Management
The incoming
contractor shall receive case files and documentation regarding
all beneficiaries under case management programs. The incoming contractor
shall ensure seamless continuity of services to those beneficiaries.
8.12 Program Integrity
The incoming contractor shall
receive case files and documentation regarding all open program integrity
cases from the outgoing contractor NLT 30 days from the SHCD. The
incoming contractor shall work with the DHA Program Integrity Office
(PI) to ensure seamless continuity of oversight of these cases.
8.13 Health Insurance Portability
And Accountability Act of 1996 (HIPAA)
The incoming contractor, as
a covered entity under HIPAA, may honor an authorization or other
express legal document obtained from an individual permitting the
use and disclosure of protected health information prior to the
compliance date (HHS Privacy Regulation, §164.532).
8.14 Installation And Operation
Of The DCS
The incoming
contractor shall have purchased, installed, configured, and connected
the personal computers and printers required to operate the DCS
NLT 60 days prior to the start of the health care delivery. See
the TSM,
Chapter 4,
for hardware, software, printer, configuration and communications requirements
and contractor installation responsibilities. Approximately 30-45
days prior to health care delivery, DHA will provide and install
the DCS application software on the incoming contractor designated
personal computers and provide on-site training for users of the
DCS in accordance with the TSM,
Chapter
4. Following the SHCD, the DCS will begin displaying identified
potential duplicate claim sets for which the incoming contractor
has responsibility for resolving. The incoming contractor shall
begin using the DCS to resolve potential duplicate claim sets in
accordance with TSM,
Chapter 4 and
the transition plan requirements.
8.15 The TOP contractor shall prepare
a mailing to the Resident Commissioners of Puerto Rico and the Northern
Mariana Islands, and the Congressional representatives for American
Samoa, Guam, and the U.S. Virgin Islands by the 45th calendar day
prior to the SHCD according to the specifications of the official
transition schedule. The proposed mailing shall be submitted to
the DHA CO, DHA COR, and TOPO, for approval no later than 90 calendar
days prior to the SHCD. The mailing shall discuss any unique processing
requirements of the contractor and any other needed information
dictated by the official transition schedule.
9.0 Transition-OUT
9.1 Transition Specifications Meeting
The outgoing contractor shall
attend a meeting with representatives of the incoming contractor
and DHA, within 15 calendar days following the effective date of
the contract. This meeting is for the purpose of developing a schedule
of transition-in/transition out activities. DHA will notify the contractor(s)
as to the exact date and location of the meeting. The outgoing contractor
shall provide a proposed transition-out plan at the Transition Specifications
Meeting.
9.2 Data
The outgoing contractor shall
provide to DHA (or, at the option of DHA, to a successor contractor)
such information as DHA shall require to facilitate transitions
from the contractor’s operations to operations under any successor
contract. All files shall be provided in a non-proprietary format
and the contractor shall include such file specifications and documentation
as may be necessary for interpretation of these files. Such information
may include, but is not limited to, the following:
• The data contained in the contractor’s
enrollment information system.
• The data contained in the contractor’s
claims processing systems.
• Information about the management
of the contract that is not considered, under applicable Federal
law, to be proprietary to the contractor.
• An automated indexing system
that can be used independently of the outgoing contractor’s data system.
(See
Chapter 9, Section 3, paragraph 2.2.2 for
Automated Indexing System requirements.)
9.3 Transition-Out Of The Contractor’s
Claims Processing Operations
Upon notice of award to another
contractor, and during the procurement process leading to an effective
date of a new contract, the contractor shall undertake the following
transition-out activities regarding services as an outgoing contractor.
9.3.1 Transfer of Electronic File
Specifications
The outgoing
contractor shall transfer to the incoming contractor by express
mail or similar overnight delivery service, NLT three calendar days
following award announcement, electronic copies of the record layouts
with specifications, formats, and definitions of fields, and data
elements, access keys and sort orders, for the following:
• The TEPRVs.
• The TRICARE Encounter Pricing
Files (TEPRCs).
• The Enrolled Beneficiary and
PCM Assignment Files.
• Mental Health Provider Files
- The outgoing contractor must assure that the incoming contractor has
been given accurate provider payment information on all mental health
providers paid under the TRICARE inpatient mental health per diem
payment system. This should include provider name; tax identification
number; address including zip code; high or low volume status; if
high volume, provide the date the provider became high volume; and
the current per diem rate along with the two prior year’s per diem
amounts. The providers under the per diem payment system must be designated
by Medicare, or meet exemption criteria, as exempt from the inpatient
mental health unit, the unit would be identified as the provider
under the TRICARE inpatient mental health per diem payment system.
9.3.2 Transfer Of ADP Files (Electronic)
The outgoing contractor shall
prepare in non-proprietary electronic format and transfer to the incoming
contractor or DHA, by the 15th calendar day following the Transition
Specifications Meeting unless otherwise negotiated by the incoming
and outgoing contractors, all specified ADP files, such as the Provider
and Pricing files, in accordance with specifications in the official
transition schedule and will continue to participate in preparation
and testing of these files until they are fully readable by the incoming
contractor or DHA.
9.3.3 Outgoing
Contractor Weekly Shipment Of History Updates
The outgoing contractor shall
transfer to the incoming contractor, in electronic format, all beneficiary history
and deductible transactions (occurring from the date of preparation
for shipment of the initial transfer of such history files) beginning
the 120th calendar day prior to the SHCD (until such a time that all
processing is completed by the outgoing contractor) in accordance
with the specifications in the official transition schedule.
9.3.3.1 During the 180 calendar days
after the SHCD when both the incoming and outgoing contractors are
processing claims, both contractors shall maintain close interface
on history update exchanges and provider file information. During
the first 60 calendar days of dual operations, the contractors shall
exchange beneficiary history updates with each contractor’s claims
processing cycle run. Thereafter, the exchange shall not be less
than twice per week until the end of dual processing.
9.3.3.2 The incoming contractor shall
assume total responsibility for the maintenance of the TEPRV beginning
with the SHCD. The incoming contractor will coordinate and cooperate
with the outgoing contractor to ensure that the outgoing contractor
can continue to process claims accurately; conversely, the outgoing
contractor has the responsibility to notify the incoming contractor
of any changes in provider status that they become aware of through
their operations.
9.3.4 Transfer
Of Non-ADP Files
The outgoing
contractor shall transfer to the incoming contractor all non-ADP
files (e.g., authorization files, clinic billing authorizations,
and tapes/CDs, which identify Congressional and DHA completed correspondence
files, appeals files, TRICARE medical utilization, and administration
files) in accordance with the specifications in the official transition
schedule. The hard copies of the Beneficiary History Files are to
be transferred to the incoming contractor or Federal Records Center
(FRC). The contractor shall provide samples and descriptions of
these files to the incoming contractor at the Transition Specification
Meeting.
9.3.5 Explanation
of Benefits (EOB) Record Data Retention and Transmittal
If the contractor elects to
retain the EOB data on a computer record, it must, in the event
of a transition to another contractor, provide either a full set
of electronic records covering the current and two prior years,
or, at the PCO’s discretion, provide the data and necessary programs
to reproduce the EOB in acceptable form and transfer such data and
programs to the successor contractor or to DHA. DHA shall be the
final authority in determining the form and/or acceptability of
the data.
9.3.6 Outgoing
Contractor Weekly Status Reporting
Until all inventories have
been processed, the outgoing contractor shall submit a weekly status
report of inventories and phase-out activities to DHA beginning
the 20th calendar day following the Specifications Meeting until
otherwise notified by the PCO to discontinue. This shall be done
in accordance with specifications of the official transition schedule.
9.3.7 Prior Authorizations and Referrals
The outgoing contractor shall
provide all prior authorizations and referrals that cover care spanning
the SHCD under the new contract or care that could potentially begin
in the incoming contractor’s health care delivery period. The outgoing
and incoming contractor shall mutually agree to the date and schedule
for transfer of this information.
9.3.8 Case Management Files
NLT 60 days prior to the SHCD
under the new contract, the outgoing contractor shall provide the incoming
contractor with all files pertaining to beneficiaries covered under
a Case Management program. Electronic files shall be provided under
a non- proprietary format. The outgoing contractor shall cooperate
with the incoming contractor to ensure seamless continuity of care
and services for all such beneficiaries.
9.3.9 Requirements Related To Transitional
Cases
The outgoing
contractor shall provide the incoming contractor with instructions
for beneficiaries and providers on how the beneficiary may obtain
assistance with transitional care.
9.3.10 Program Integrity Files
NLT 30 days prior to the SHCD
under the new contract, the outgoing contractor shall provide the incoming
contractor with all fraud and abuse information it has collected
during the tenure of the contract relevant to TRICARE providers
and beneficiaries. For example, (not all inclusive) high dollar initial
draft fraud cases, post payment utilization and reviews that identified
potential fraud, established provider/beneficiary outlier watch
lists, list of providers on prepayment review, copies of educational letters,
regional fraud trend/outlier reports, Fraudline reports, and beneficiary
complaints related to health care fraud. Electronic files shall
be provided under a non-proprietary format.
9.4 Final Processing Of Outgoing
Contractor
The outgoing
contractor shall:
• Process all claims received
through the last date of the outgoing contractor’s healthcare delivery. Processing
of these claims, including adjustments, shall be completed with
180 days following the start of the incoming TOP contractor’s healthcare
delivery period.
• All claims shall meet the same
standards as outlined in the current outgoing contract. Any residual claim
received after SHCD shall be forwarded to the incoming contractor
within 24 hours of receipt. Claims for the Philippines, that have
been pended for development of missing/required documentation or
pended for provider certification, shall be denied on the 179th
day if information was not received or certification was not complete.
Any residual information related to the Philippines claims received
after SHCD shall be forwarded to the incoming contractor with 24
hours of receipt.
• Be liable, after the termination
of services under this contract, for any payments to subcontractors of
the contractor arising from events that took place during the period
of this contract.
• Process all correspondence,
allowable charge complaints, and incoming telephonic inquiries which pertain
to claims or services processed or delivered under this contract
within the time frames established for response by the standards
of the contract.
• Complete all appeal and grievance
cases that pertain to claims or services processed or delivered under
this contract within the time frames established for response by
the standards of the contract.
9.4.1 Correction of Edit Rejects
The outgoing contractor shall
retain sufficient resources to ensure correction (and reprocessing through
DHA) of all TED record edit errors NLT 210 calendar days following
the start of the incoming contractor’s health care delivery.
9.4.2 Transition-Out of the Automated
TRICARE DCS
The outgoing
contractor shall phase-out the use of the automated TRICARE DCS
in accordance with the TSM,
Chapter 4 and
transition plan requirements.
9.4.3 Transition-Out Of The Contractor’s
Provider Network, TSCs, And MTF Agreements
9.4.3.1 Upon notice of award to another
contractor, the outgoing contractor shall provide full cooperation
and support to the incoming contractor, to allow an orderly transition,
without interruption, of all functions relating to the MTF interface
and the establishment of a provider network by the incoming contractor.
This shall include, but is not limited to, data relating to on-site
service centers, equipment, telephones and all other functions having
an impact on the MTFs.
9.4.3.2 Within 15 calendar days of
the Transitions Specifications Meeting the outgoing contractor shall
draft and submit a revised plan for transition of the MTF interfaces.
Resolution of differences identified through the coordination process
must be accomplished in collaboration with TOPO.
9.4.3.3 The outgoing contractor shall
ensure a HCF function continues through the last date of health
care delivery under the current contract, unless otherwise negotiated
with the incoming contractor during the Transition Specifications
Meeting. The outgoing contractor shall also vacate the TSCs on the
40th calendar day prior to the start of the health care delivery
and establish a centralized HCF function.
9.4.3.4 The outgoing contractor shall
continue to issue prior authorizations for care for which it is financially
responsible. However, authorization-related information shall be
shared between the incoming and the outgoing contractors to preclude
requiring a provider or beneficiary to duplicate the paperwork and
other effort related to establishing prior authorizations. The outgoing
contractor may issue prior authorizations as late as midnight on
the day prior to the end of its health care delivery for inpatient
stays that will continue as transitional cases. The two contractors
shall interface on the clinical issues of a case where both contractors
will, or can reasonably expect to have periods of liability for
the same EOC.
9.4.3.5 The outgoing contractor shall
maintain toll-free lines and web-based customer service capabilities,
accessible to the public during the first 90 calendar days of dual
operations in order to properly respond to inquiries related to
claims processed for services incurred during the period of their
respective liability. Beneficiary inquiry lines will continue to
be staffed as defined in the contract.
9.5 Transition-Out of Enrollment
Activities
9.5.1 Prior
to the SHCD under the successor contract, for all enrollment renewals
or payments in which the new enrollment period or period covered
by the premium payment will begin under the new contract, the outgoing
contractor shall amend renewal notices and billing statements (or
include a stuffer/insert) to advise the enrollee to direct any enrollment-related
correspondence and enrollment fee payments to the successor contractor.
9.5.2 Any enrollment-related correspondence
and/or enrollment fee payments subsequently received by the outgoing
contractor shall be forwarded to the incoming contractor within
three working days of receipt.
9.5.3 The outgoing contractor shall
terminate marketing and enrollment activity 40 calendar days prior
to the start of the incoming contractor’s health care delivery.
Any enrollment requests or applications received after the 40th
calendar day shall be transferred to the incoming contractor by overnight
delivery at the outgoing contractor’s expense.
9.5.4 Throughout the enrollment dual
processing period, the outgoing and incoming contractors shall coordinate
enrollment files 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.
9.6 Cost Accounting
If the outgoing contractor
succeeds itself, costs related to each contract shall be kept separate
for purposes of contract accountability, according to the above
guidelines.
9.7 Records
Disposition
The contractor
shall include a records disposition plan as part of the transition-out
plan submitted to DHA at the Transition Specifications Meeting.
9.8 Provide Information
The contractor shall, upon
receipt of a written request from DHA, provide to potential offerors
such items and data as required by DHA. This shall include non-proprietary
information, such as record formats and specifications, field descriptions
and data elements, claims and correspondence volumes, etc.
9.9 Recoupment
9.9.1 Installment Cases
The outgoing contractor shall
transfer all installment cases to DHA, Office of General Counsel
(OGC), Claims Collection Section (CCS). A list of all installment
cases to be transferred, shall be provided by fax or encrypted email
to CCS before the cases are transferred.
9.9.2 Cases Less Than 12 Months
The outgoing contractor shall
transfer cases greater or equal to $110 ($30 for pharmacy) and that
are less than 12 months old to the incoming contractor, who shall
assume management of the cases. Cases received by the incoming contractor
shall be managed until the debt is collected in full, or combined with
any other under $600 active recoupment case against the same debtor
to equal $600 or more and transferred to DHA, OGC, CCS. Cases that
do not meet the criteria, shall be written off by the contractor.
9.10 Transition Out of TED Activities
Transition-out activities related
to TED shall be accomplished no later than 14 months after the start
of health care delivery for the incoming contractor. At 180 days
after the end of healthcare delivery the contractor shall not issue
or reissue any checks/payments unless authorized by DHA, CRM. The contractor
is required to keep all bank accounts associated with claims payments
open until all outstanding checks/payments have either cleared or
stale date. If a payment stale dates, the contractor is required
to cancel the associated TED data with DHA and notify the incoming
contractor. The contractor may cease TED data submissions when all
TED reported checks/payments issued under this contract have cleared
or stale date. The contractor may request (at no-cost to the government)
an extension for TEDs processing after the 14 month period ends
if more time is needed to complete stale date check processing.