1.0 Provider Networks
1.1 The contractor shall establish
an adequate network of providers in accordance with access standards
outlined in
Chapter 5, Section 1 and 45 Code of Federal
Regulations (CFR) 156.230, with minimal impact to beneficiaries.
Provider network development shall be completed no later than 30 days
prior to the start of health care delivery (SHCD). The contractor
shall establish an adequate network of providers for Prime Service
Areas (PSAs)
, Base Realignment and Closure (BRAC)
sites, and non-PSAs in the Region. For the purposes
of assessing adequacy, standards shall apply to all PSAs in the region.
1.2 The
contractor shall ensure the network has the capability and capacity
to permit each beneficiary enrolled in TRICARE Prime, to enroll
to a civilian Primary Care Manager (PCM) prior to the start of Option
Period 1 and residing outside of PSAs under this contract to enroll
to a PSA PCM, provided the beneficiary resides less than 100 miles
from an available network PCM in the PSA and waives both primary
and specialty care travel time standards. Beneficiaries enrolled
in Prime to a civilian PCM prior to the beginning of Option Period
1 who reside outside of PSAs under this contract and are 100 miles
or more from an available PCM in the PSA network, shall not be permitted
to continue their enrollment.
1.3 The contractor
shall ensure TRICARE Select access standards for appointments for
health care that meet or exceed those of high-performing health
care systems in the United States. The contractor shall utilize
sizing models to establish network contracting targets sufficient
to support the program’s access standards and network expansion
that meets or exceeds the TRICARE Select requirement by January
1, 2018. See Chapter 5, Section 1.
1.4 The contractor shall ensure
accurate and complete provider information is entered into contractor
and Government automated provider files that interface directly
with the Defense Enrollment and Eligibility Reporting System (DEERS),
contractor medical management systems, and supporting medical management
systems identified by the Government not later than 30 days prior
to SHCD.
1.5 The contractor shall comply
with the Contract Data Requirements List (CDRL) requirements for providing
the contractor’s approach for meeting Access to Care requirements.
2.0
Execution
Of Agreements With Contract Providers
2.1 All contract
provider agreements shall be executed, and loaded to the incoming
contractor’s system, 60 calendar days prior to the SHCD, or at such
other time as is mutually agreed between the contractor and the
Defense Health Agency (DHA).
2.2 The incoming
contractor shall begin reporting on network adequacy on a monthly
basis during the transition.
4.0 Provider Certification
4.1 The outgoing contractor shall
transfer the provider certification documentation to the incoming
contractor. The incoming contractor shall limit certification actions
to new providers and shall verify a provider’s credentials once,
upon application to become a certified provider.
4.2 The contractor shall conduct
an audit, which must include either 5% or 50, whichever is less,
of all prime contractors’ and subcontractors’ individual network
provider credentialing and privileging files to ensure that information
is appropriately verified. The audit shall be completed prior to
the SHCD. Thirty calendar days prior to the audit, the contractor
shall invite the Director, TRICARE Regional Offices (TROs), or for
the TRICARE Dual Eligible Fiscal Intermediary Contract (TDEFIC)
and the Contracting Officer’s Representative (COR) to monitor and/or
participate in the audit. Not less than 85% of the audited files
shall be in full compliance with all provider file requirements.
Within five business days of the completion of the audit’s provider
file review, the contractor shall submit to the Procuring Contracting
Officer (PCO) and the Director, TROs, or the TDEFIC COR, a written
Corrective Action Plan (CAP), which addresses all credentialing
and privileging files not in full compliance. Within 30 calendar days
after completion of the audit’s provider file review, the incomplete
or incorrect files shall be corrected to full compliance.
4.3 Provider Certification File
No later than 30 days after
contract award and on a monthly basis until the SHCD, the outgoing contractor
shall provide the incoming contractor with copies of all provider
certification files.
4.4 Phase-Out
Of The Contractor’s Provider Network, TRICARE Service Centers (TSCs) (TRICARE
Overseas Contract Only), And Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM) Agreements
4.4.1 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/eMSM 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, resource sharing agreements,
equipment, telephones and all other functions having an impact on
the MTFs/eMSMs.
4.4.2 Within
15 calendar days of the Transitions Specifications Meeting the outgoing
contractor shall draft and submit a revised plan for transition
of the MTF/eMSM interfaces. Resolution of differences identified
through the coordination process must be accomplished in collaboration
with the Transition Monitor appointed by DHA and according to the
guidelines in the transition schedule.
4.4.3 The outgoing
contractor shall ensure a Health Care Finder (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 (TRICARE overseas contract only) on the 40th
calendar day prior to the SHCD and establish a centralized HCF function.
4.4.4 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.
4.4.5 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 liability. Beneficiary inquiry lines will continue
to be staffed as defined in the contract. In general, the outgoing
contractor shall maintain adequate toll-free line coverage to ensure
that the blockage rate does not exceed the blockage rate on the
contractor’s most critical private or other Government business
access line.
5.0 Performance Readiness Validation
(PRV)/Performance Readiness Assessment And Verification (PRAV)
During transition, the incoming
contractor’s performance readiness status regarding provider networks will
be subject to PRV/PRAV reviews as described below.
5.1 Provider Network PRV
5.1.1 The contractor shall validate
they have established an adequate network of providers for all PSAs
in the region. The contractor will produce evidence of network adequacy
for PCMs, Behavioral Health (BH) providers, specialty care providers,
and health care facilities through comparison of the number of signed
network agreements and the contractor’s target in their Network
Implementation Plan. The contractor shall validate that signed providers
meet credentialing documentation requirements. For the purposes
of assessing adequacy, the validation shall assess all PSAs in the
region individually and not the region as whole.
5.1.1.1 Two hundred and forty days
prior to SHCD, the contractor shall finalize network modeling and
submit their Network Implementation Plan. Interim self-assessment
reports will be provided to the Government at 30 day intervals following
submission of the Network Implementation Plan.
5.1.1.2 Sixty days prior to SHCD, the
contractor shall have completed provider network development including
completion of provider agreements and credentialing.
5.1.2 The contractor shall validate
accurate and complete provider system loads for PCMs and BH providers.
The contractor will develop “load file completion reports” which
compare the percentage of providers loaded into the requisite systems
with the number of providers required by the contractor’s Network
Implementation Plan. The reports shall include the contractor’s
accuracy attestation to the Government regarding the total number
of provider system loads by category (PCMs and BH providers) and
the percentage of records loaded that meet the scheduled accuracy
threshold listed below in all data fields. Contractor validation
goals shall, at a minimum, meet the following:
• Fifty percent (50%) of PCMs
and BH providers loaded no later than 120 days prior to SHCD at
a 90% accuracy rate.
• Seventy-five percent (75%)
of PCMs and BH providers loaded no later than 90 days prior to SHCD
at a 90% accuracy rate.
• One hundred percent (100%)
of PCMs and BH providers loaded no later than 60 days prior to SHCD at
a 95% accuracy rate.
The Government will consider
exceptions to the 100%/60 day requirement in medically underserved areas.
5.1.3 The contractor shall validate
accurate and complete specialty provider (other than BH providers)
and health care facility system loads. The contractor will develop
“load file completion reports” which compare the percentage of specialty
providers and facilities loaded into the requisite systems with
the number of specialty providers and facilities required by the
contractor’s Network Implementation Plan. The reports shall include
the contractor’s accuracy attestation to the Government regarding
the total number of system loads by category (specialty providers
and facilities) and the percentage of total records that meet the
scheduled accuracy threshold listed below in all data fields. Contractor
validation goals shall, at a minimum, meet the following:
• Fifty percent (50%) of specialty
care providers and health care facilities loaded no later than 120 days
prior to SHCD at a 90% accuracy rate.
• Seventy-five percent (75%)
of specialty care providers and health care facilities loaded no
later than 90 days prior to SHCD at a 90% accuracy rate.
• One hundred percent (100%)
of specialty care providers and health care facilities loaded no
later than 60 days prior to SHCD at a 95% accuracy rate.
The Government will consider
exceptions to the 100%/60 day requirement in medically underserved areas.
5.1.4 The contractor shall validate
the completeness and accuracy of the online directory of network
providers. The contractor shall provide a time line for completing
the online provider directory and develop validation reports which
compare the number of network providers and facilities who have
been entered in the online directory to the total number of network
providers and facilities required by the contractor’s Network Implementation
Plan Validation reports shall begin 120 days prior to SHCD and continue
at 30 day intervals according to the time lines and scheduled accuracy thresholds
listed below, until the complete provider directory is online and
operational 60 days prior to SHCD at a 95% accuracy rate. Accuracy
calculations will be based on each data field as opposed to each record
for each PSA. Contractor validation goals shall, at a minimum, meet
the following:
• Fifty percent (50%) of network
providers and health care facilities entered no later than 120 days prior
to SHCD at a 90% accuracy rate.
• Seventy-five percent (75%)
of network providers and health care facilities entered no later
than 90 days prior to SHCD at a 90% accuracy rate.
• One hundred percent (100%)
of network providers and health care facilities entered no later
than 60 days prior to SHCD at a 95% accuracy rate.
• Complete provider directory
online and operational 60 days prior to SHCD at a 95% accuracy rate.
The Government will consider
exceptions to the 100%/60 days prior to SHCD requirement in medically underserved
areas.
5.2 Provider
Network PRAV
5.2.1 The contractor shall comply
with the Government’s approach for assessment and verification of
the contractor’s performance readiness regarding provider networks
as described above. If, after review, the Government finds the contractor’s
performance readiness for claims processing to be deficient, the
contractor must submit a detailed mitigation plan no later than
10 business days following the Government’s findings.
5.2.2 Specific PRAV activities, assessment
techniques, and performance readiness thresholds will be identified
by the Government during the Transition Specification Meeting.