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TRICARE Operations Manual 6010.59-M, April 1, 2015
Transitions
Chapter 2
Section 10
Other Requirements
Revision:  C-26, May 30, 2018
1.0  PROGRAM INTEGRITY
1.1  The incoming contractor shall receive case files and documentation regarding all open program integrity cases from the outgoing contractor no later than 30 days from the start of health care delivery (SHCD). The incoming contractor shall work with the Defense Health Agency (DHA) Program Integrity Office (PI) to ensure seamless continuity of oversight of these cases. This shall include any open leads under development, proactive action items, etc., and not limited to cases.
1.2  The outgoing contractor shall provide weekly updates of program integrity case file(s), including new cases initiated through the end of the outgoing contractor’s contract delivery period. Details for reporting are contained in DD Form 1423, Contract Data Requirements List (CDRL), located in Section J of the applicable contract. This shall also include active leads and cases under development that have not yet been forwarded to DHA PI.
2.0  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).
3.0  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.
4.0  RECORDS MANAGEMENT
The incoming contractor’s Records Management liaison shall attend the first available DHA provided records management training following contract award in accordance with Chapter 9.
4.1  The outgoing contractor shall provide an automated indexing system that can be used independently of the contractor’s data system as outlined in Chapter 9, Section 3, in the event of a transition.
4.2  The outgoing contractor shall maintain a complete set of documentation to be turned over to the incoming contractor in the event of a transition. The documentation shall describe the metadata, how the files are formatted, and other information that will allow DHA or an incoming contractor to efficiently and effectively retrieve the records. If the outgoing contractor does not have an incoming contractor to transfer documentation to see Chapter 9, Section 4, for additional guidance on records disposal, storage, and transfer.
4.3  Upon direction from DHA, the incumbent shall also be prepared to present the incoming contractor with standard claim images, in Tagged Imaged File Format (TIFF) or searchable Portable Document Format (PDF). Valid alternatives shall be submitted to DHA for review and consideration.
4.4  Transfer Of Non-ADP Files
The outgoing contractor shall transfer to the incoming contractor all non-Automated Data Processing (ADP) files (e.g., authorization files, clinic billing authorizations, and tapes/CDs, which identify Prime Service Areas (PSAs), Congressional, and DHA completed correspondence files, appeals files, TRICARE medical utilization, and administration files) in accordance with the specifications in the official transition schedule and Chapter 9. The hard copies of the Beneficiary History Files are to be transferred to the incoming contractor or Federal Records Center (FRC) as required by Chapter 9. The outgoing contractor shall provide samples and descriptions of these files to the incoming contractor at the Transition Specification Meeting.
4.5  Transfer of Electronic Records
4.5.1  During transition, all DHA electronic records not eligible for destruction along with their associated metadata shall be transferred to the incoming contractor. DHA electronic records suitable for transfer shall be identified through meetings between contractors, the DHA Records Management Officer and the DHA Contracting Office. The contractor shall develop a process for transferring the data to the incoming contractor that ensures no metadata or their associated record objects lost in the transition process.
4.5.2  The documentation must adequately identify, service, and interpret electronic records designated for storage by DHA and the documentation must be transferred with the records.
4.6  Records Disposition
The outgoing contractor shall comply with the provisions of Chapter 9, in final disposition of all files and documentation.
4.6.1  Once the transition of records and materials has been accomplished, the outgoing contractor shall destroy all copies to include backup data in accordance with 36 CFR Part 1226, “Implementing Disposition”. The contractor shall not dispose or destroy any copies or backup data prior to formal, written notification from the DHA Contracting Office or DHA Records Management Office. A formal record of destruction or certificate shall be provided to the DHA Contracting Office documenting what was destroyed, the date(s) destroyed and by whom. This certificate of destruction shall be provided to the DHA Records Management Officer. The contractor shall include a records disposition plan as part of the phase-out plan submitted to DHA at the Transition Specifications Meeting.
4.6.2  In the event that the outgoing contractor does not have an incoming contractor to accept transfer of electronic records, refer to Chapter 9, Section 4, for additional guidance on records disposal, storage, and transfer.
4.7  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.
5.0  RECOUPMENTS
5.1  Recoupment
5.1.1  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.
5.1.2  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.
5.1.3  Cases Greater Than 12 Months
5.1.3.1  The outgoing contractor shall write off cases less than $600 ($30 for pharmacy) that when combined with other cases do not equal $600 or more, and reported on line A5 of the Accounts Receivable Summary Report (refer to the CDRL located in Section J of the contract).
5.1.3.2  The outgoing contractor shall transfer cases greater or equal to $600 to CCS. A list of all cases to be transferred to CCS shall be provided by fax or encrypted email to CCS before the cases are transferred.
5.1.4  General
5.1.4.1  The incoming contractor and CCS, shall receive the designated cases from the outgoing contractor no later than 30 days after the SHCD. The incoming contractor shall reflect the number of cases and the amount of the outstanding debt received from the outgoing contractor on the next monthly Accounts Receivables Report following the date of transition. (The details for content and submission of this report are contained in the CDRL, refer to the CDRL located in Section J of the contract.)
5.1.4.2  The outgoing contractor shall submit a credit adjustment to include all amounts recouped up to the point of transition. The final Accounts Receivable Report for the outgoing contractor shall reflect the number of cases and the amount of the outstanding debt transferred to the incoming contractor.
5.2  Third Party Recovery
The outgoing contractor shall transfer court-ordered restitution cases to the incoming contractor for continued collection. The incoming contractor shall continue to collect whatever payments are forthcoming and advise the probation officer when a payment is missed, in accordance with Chapter 10, Section 5.
6.0  APPEALS AND HEARINGS
The incoming contractor shall develop and maintain appeals processing guidelines, desk instructions, and reference materials relevant to Chapter 11, Section 8 and Chapter 12. One complete set of these materials shall be provided to the Government as identified by DD Form 1423, CDRL, located in Section J of the applicable contract, with updates provided as changes occur.
6.1  Appeals Claims Spanning Multiple Jurisdictions
Appeals for claims processed by both the incoming and outgoing contractors, during the transition period, shall be reviewed separately by each contractor in accordance with the Chapter 12. Appeals may be received involving more than one jurisdiction. Appeals may be received involving more than one jurisdiction. For example, a case may involve services processed by both the outgoing contractor and the incoming contractor in a period of transition and will require separate review. The contractor receiving the appeal shall notify the appealing party that the services will be reviewed separately by the outgoing contractor and the incoming contractor. The notification shall also include the name and address of each contractor performing the reviews. The contractor shall photocopy the written appeal request, the notification to the appealing party of the referral, and other relevant information and forward the photocopies to the other contractor with an explanation of the action taken within 21 calendar days of the stamped date of receipt of the appeal.
6.2  Assistance to Incoming Contractor, TRICARE Quality Management Contract (TQMC), and DHA During Transition
During transition, the outgoing contractor or the TQMC shall make available, upon request, individual cases completed during the transition period and not yet transferred to the incoming contractor or TQMC. In no case shall mailing the appeal file to the incoming contractor, the TQMC, or DHA occur later than five workdays after receipt of a telephonic, written or fax request from DHA or the incoming contractor during a transition period.
6.3  Appeal Case Files
Upon request from the incoming contractor, the outgoing contractor shall transfer individual cases completed during the transition period and not yet transferred to the incoming contractor in accordance with the Chapter 12.
7.0  DHA COMMUNICATIONS
7.1  Interface Requirements
DHA Communications will meet with the incoming contractor within 60 calendar days following contract award to develop and establish a Memorandum of Understanding (MOU). Details for the MOU are identified by DD Form 1423, CDRL, located in Section J of the applicable contract. The MOU shall also address the ordering and bulk shipment of materials. The MOU shall be effective no later than 30 days following the meeting between DHA Communications and the contractor.
7.2  Initial Ordering of Educational Materials
Following contract award, initial requests for desired educational materials shall be submitted in accordance with Chapter 11, Section 1 to DHA Communications. Within 30 days of the request, DHA Communications will host a meeting with the TRICARE Beneficiary Publication Committee. The contractor shall provide one representative for attendance and participation in the work group meeting to be held in the Washington, DC area. Meetings may be attended via teleconference, video telecommunications or in person, as directed by the Government. Upon determination of the core products, contractors shall submit a request for copies required and delivery dates requested. The contractor shall provide DHA Communications with a single Point Of Contact (POC) and address(es) for delivery of educational materials.
8.0  MEDICAL MANAGEMENT TRAINING
The contractor shall participate in DHA sponsored medical management training as requested, to include coordination of training schedules and the development of the agenda and training materials. The incoming contractor shall participate in up to two four-day training sessions during the transition period in their respective region. The location of the training will be designated by DHA.
9.0  INTERNAL QUALITY MANAGEMENT/QUALITY IMPROVEMENT (QM/QI) PROGRAM
The contractor shall electronically submit documents describing the QM/QI Program, as identified by DD Form 1423, CDRL, located in Section J of the applicable contract.
10.0  SUBMISSION
10.1  Deliverables that provide data for measuring objective requirements require submission in Microsoft® Excel format with metric data reported in the same cell within the same worksheet for each reporting period. This may require an additional worksheet be added to the contractor’s deliverable. If required, the new report template will be provided by the Government prior to the start of the first reporting period.
10.2  The method of distribution and file format of each deliverable is identified by DD Form 1423, CDRL, located in Section J of the applicable contract. Distribution of deliverables to other agencies (Government and contractors) as specified by the Government is the responsibility of the contractor.
11.0  DHA Evaluation Of Non-United States (U.S.) Food And Drug Administration (FDA) Approved Laboratory Developed Tests (LDTS) Demonstration Project
The outgoing contractor shall provide a list of all beneficiaries under demonstration approved LDT care to the incoming contractor.
12.0  Continued Healthcare Benefit Program (CHCBP) (Applies To The East Region Contractor Only)
12.1  No later than six months prior to the SHCD, the contractor shall provide the Contracting Officer’s Representative (COR) with the contractor’s mailing address and toll- free telephone number.
12.2  No later than four months prior to the SHCD, the Government will furnish the contractor with a sample of the CHCBP Termination Notice format.
13.0  Performance Readiness Validation (PRV)/performance Readiness Assessment And Verification (PRAV)
During transition, the incoming contractor’s performance readiness status regarding management will be subject to PRV/PRAV reviews as described below.
13.1  Management PRV
13.1.1  During the transition-in period, the contractor shall continually monitor and validate its progress towards establishing and maintaining experienced and qualified key personnel and sufficient staffing and management support to meet the requirements of this contract. Progress shall be monitored based on the time lines and goals established in the Integrated Master Plan/Integrated Master Schedule (IMP/IMS). Ninety days prior to SHCD, the contractor shall validate that all key personnel, staff, and management support personnel have been identified and that all necessary administrative actions (e.g., trustworthiness determinations, training) have been completed or are scheduled for completion prior to SHCD. The validation results shall be briefed to the Government 75 days prior to SHCD.
13.1.2  During the transition-in period, the contractor shall continually monitor and validate whether the contractor’s initial submission of the Quality Management and Quality Improvement (QM/QI) Program Plan provides a comprehensive and coordinated approach that facilitates problem identification and resolution of issues. Lessons learned shall be documented in writing and incorporated into subsequent submissions of the QM/QI Program Plan. The validation results shall be briefed to the Government 75 days prior to SHCD.
13.1.3  The contractor shall validate its ability to provide Government users with access to all data as required by the contract via a data access interface mutually agreed upon by the TRO and Managed Care Support Contractor (MCSC) and available prior to SHCD. The validation results shall be briefed to the Government 60 days prior to SHCD.
13.1.4  The contractor shall validate its ability to provide training and ongoing customer support for Government personnel who access the contractor’s data information system/data repository as required by the contract. The validation results shall be briefed to the Government 75 days prior to SHCD.
13.1.5  The contractor shall validate its ability to provide the Government with access to the contractor’s commercially available web-based mapping software for calculating distance and time standards. The contractor shall provide the Government with access to the software at no additional cost. The validation results shall be briefed to the Government 120 calendar days prior to SHCD.
13.2  Management PRAV
13.2.1  The contractor shall comply with the Government’s approach for assessment and verification of the contractor’s performance readiness regarding management as described above. If, after review, the Government finds the contractor’s performance readiness for management to be deficient, the contractor must submit a detailed mitigation plan no later than 10 days business days following the Government’s findings.
13.2.2  Specific PRAV activities, assessment techniques, and performance readiness thresholds will be identified by the Government during the Transition Specification Meeting.
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