2.0 Performance Readiness Validation
(PRV)/performance Readiness Assessment And Verification (PRAV)
During transition, the incoming
contractor’s performance readiness status regarding referral management
will be subject to PRV/PRAV reviews as described below.
2.1 Referral Management PRV
2.1.1 The contractor shall validate
establishing referral management system interfaces with MTF/eMSM
referral management systems. Establishing an MTF/eMSM interface
must meet two criteria: 1) MTF/eMSM can send and receive referrals
with no technical problems, and (2) contractor sends ROFRs in accordance
with the MTF/eMSM capability table with 95% accuracy. Milestones
for validating MTF/eMSM interfaces are:
• Fifty percent (50%) of MTF/eMSM
interfaces are established 90 days prior to SHCD.
• Seventy-five percent (75%)
of MTF/eMSM interfaces are established 75 days prior to SHCD.
• Ninety-five percent (95%) of
MTF/eMSM interfaces are established 60 days prior to SHCD.
2.1.2 Sixty days prior to SHCD, the
contractor shall validate its systems can effectively interface with
the Government’s RMS, Defense Enrollment Eligibility Reporting System
(DEERS), TRICARE Regional Offices (TROs), MTFs/eMSMs, claims, Network
Provider Directory, and Network Providers and the contractor’s portal/web
site. The contractor shall inspect, test, and produce connectivity
test results on all interfaces.
2.1.3 Fifty
days prior to SHCD, the contractor shall validate all aspects of
its referral, authorization, ROFR and command approval process by
utilizing test scenarios which include referrals to MTF/eMSM and
Network providers. The validation must encompass all necessary beneficiary
categories to include processing referrals for beneficiaries with
Medicare Part A (but under age 65) and still enrolled in TRICARE
Prime and referrals from United States Coast Guard (USCG) facilities.
The validation must incorporate a review of the contractor’s ability
to utilize open authorizations that were transferred from the outgoing
contractor.
2.1.3.1 The contractor shall validate
that their system can timely and accurately communicate referral,
authorization and ROFR determinations with beneficiaries, network
providers, MTFs/eMSMs, Government systems and claims systems without
technical problems. The contractor shall demonstrate beneficiary
and provider ability to view/print authorization from the contractor’s
web site/portal. The contractor shall demonstrate accurate letter
generation.
2.1.3.2 The contractor’s validation
shall demonstrate their referral management system’s ability to accurately
process 90% of referrals within two working days and 100% within
three working days. The contractor shall validate its Referral Management
beneficiary communications system--approval/denial letters, etc.
is accessible by MTFs/eMSM, TROs, and beneficiaries.
2.1.3.3 The contractor shall validate
that referrals and ROFRs processed meet Program requirements with
a 95% accuracy rate. To be considered accurate, processed referrals/ROFRs
shall include:
• Correct Beneficiary.
• Correct Beneficiary Demographics.
• To include sponsor’s last four
Social Security Number (SSN) or Department of Defense (DoD) ID Number.
• Date of Birth (DOB).
• Unique Identifier Number (UIN)
is present if MTF/eMSM generated request.
• Correct Servicing Provider.
• Correct Servicing Specialty.
• Correct Episode of Care (EOC).
• Evaluate and Treat.
• Evaluate only.
• Number of visits.
• Length of authorization.
• Range of Current Procedural
Terminology (CPT) codes.
2.2 Referral Management PRAV
2.2.1 The contractor shall comply
with the Government’s approach for assessment and verification of
the contractor’s performance readiness regarding referral management
as described above. If, after review, the Government finds the contractor’s
performance readiness for referral management to be deficient, the
contractor must submit a detailed mitigation plan no later than
10 business days following the Government’s findings.
2.2.2 Specific PRAV activities, assessment
techniques, and performance readiness thresholds will be identified
by the Government during the Transition Specification Meeting.